Columbia  ©nibergitp  '^"^^ 
intteCitpofi^eto|9orfe 

COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


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THE 


PATHOLOGY  AND  TREATMENT 


YEI^EREAL   DISEASES. 


BY 

FREEMAN  J.  BUMSTEAD,  M.D.,LL.D., 

LATE    PROFESSOR   OF    VEKEREAL    DISEASBS    AT   THE    COLLEGE   OF    PHYSICIANS    AND    SURGEONS, 

NEW  YORK  :    LATE  SORGEON  TO  THE  NEW  YORK  EYE  AND  EAR  INFIRMARY  ; 

CONSULTING  SURGEON  TO  CHARITY  HOSPITAL,  ETC.  ETC. 


FOURTH  EDITION,  REVISED,  ENLARGED, 
AND  IN  GREAT  PART  REWRITTEN  BY  THE  AUTHOR  AND 
BY 

ROBERT  W.  TAYLOR,  A.M.,M.D., 

PROFESSOR  OF  dKIN  DISEASES  15  THE  UNIVERSITY  OF  VERMONT  ;    ATTENDING  SURGEON 
TO  CHAKITT   HOSPITAL,  ETC.   ETC. 

WITH  ONE   HUNDRED  AND  THIRTY-EIGHT  WOOD-CUTS. 


P  H  I  L  A  D  E  L  P  II I  A : 

HENEY     O.     LEA 

1879. 


Entered  according  to  Act  of  Congress,  in  the  year  1879,  by 

HENRY    C.    LEA, 

in  tlie  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


COLLINS,    P  R I N  T  K  K . 


PREFACE  TO  THE  FOURTH  EDITION. 


SixcE  the  publication  of  the  hist  edition  of  this  work,  the 
contributions  to  our  knowledge  of  Venereal  Diseases  have  been 
extremely  numerous  and  important.  They  have  included  tissues 
of  the  human  frame,  as  the  brain  and  nervous  system,  which  but 
a  few  years  ago  were  supposed  to  be  exempt  from  the  ravages  of 
syphilis,  but  which  are  now  known  to  be  the  seat  of  its  frequent 
manifestation.  Additional  light  has  been  thrown  upon  many  other 
affections  and  upon  many  questions  of  pathology,  which  were 
erroneously  supposed  to  be  exhausted.  Increased  interest  has 
been  awakened  in  this  department  in  almost  every  civilized 
countr3^  Learned  bodies,  as  the  Pathological  Society  of  London, 
have  devoted  session  after  session  for  months  to  the  consideration 
and  discussion  of  the  more  obscure  forms  of  syphilis.  Xew 
workers  have  constantly  been  entering  the  field,  and  the  mass  of 
material  now  at  our  disposal  is  simply  immense. 

The  time  has  gone  by  when  a  treatise  upon  any  medical  or 
surgical  subject,  giving  solely  the  experience  and  views  of  the 
author,  will  find  more  than  a  limited  number  of  readers.  With- 
out undervaluing  the  experience  of  the  author,  both  for  its  own 
sake  and  for  the  ability  it  gives  him  to  weigh  and  sift  the  experi- 
ence of  others,  the  chief  object  of  the  reader  is  to  ascertain  the 
present  state  of  our  knowledge  upon  the  subject  of  which  he 
reads.  To  accomplish  this  there  must  be  collected  for  him,  in  a 
clear  and  acceptable  form,  every  important  fact  and  theory  from 
many  widely  distributed  sources  to  which  he  has  no  access, 
or  which  he  would  not  have  the  time,  and,  possibly,  not  the 
ability  to  use,  if  he  had  them  at  hand.      But  in  the  present 


IV  PREFACE    TO    THE    FOURTH    EDITION. 

instance,  as  now  in  many  departments  of  science,  the  material  to 
be  collected  was  so  scattered  in  various  volumes  of  Transactions, 
in  monographs,  and  in  medical  journals,  and  so  many  specialties 
had  sprung  up  within  this  one  specialty,  that  the  labor  involved 
in  issuing  a  fourth  edition  of  this  work  was  recognized  as  formid- 
able, and  even  sufficient  to  afford  some  ground  for  the  assertion 
made  by  one  well  versed  in  the  subject,  that:  "In  future  it  will 
be  impossible  to  include  Venereal  Diseases  in  a  single  treatise ; 
they  can  only  be  studied  and  known  in  separate  monographs." 

That,  however,  such  a  treatise  on  a  level  with  our  present 
knowledge  was  demanded  by  the  Profession,  and  that,  if  well 
executed,  it  would  not  fail  to  meet  with  the  same  favorable 
reception  which  had  been  accorded  to  the  three  previous  editions 
of  this  work,  was  never  for  a  moment  doubted  by  the  author, 
whose  chief  embarrassment  lay  in  the  want  of  time  and  strength. 
Fortunately  he  was  able  to  overcome  this  difficulty  by  the  asso- 
ciation with  him  of  a  gentleman.  Dr.  R.  W.  Tajdor,  of  this  city,  who 
was  already  well  known  in  the  United  States  and  abroad  by  his 
original  contributions  to  our  knowledge  of  Venereal  Diseases,  and 
who  was  admirably  adapted,  both  by  his  own  experience  and  by 
his  extensive  reading,  to  engage  in  a  work  which  has  occupied  us 
conjointly  for  the  last  two  years.  Still  further.  Dr.  E.  G.  Loring, 
Surgeon  to  the  New  York  Eye  Infirmary,  who  revised  the  Chapter 
on  Diseases  of  the  Eye  in  the  last  edition,  kindly  consented  to  do 
the  same  in  this.  We  are  also  under  great  obligation  to  Dr.  C.  H. 
Knight  for  most  valuable  assistance  rendered  us  in  preparing  the 
manuscript,  and  also  for  the  very  complete  index  appended  to  the 
work. 

As  a  result  of  these  labors,  the  reader  will  find  rather  a  new 
work  than  an  old  one  revised,  more  portly  in  its  dimensions  than 
the  last  edition  by  131  pages,  but,  as  a  reduced  size  of  ty})e  has 
been  employed,  the  volume  is  estimated  to  contain  about  one-half 
more  reading  matter  than  its  predecessor.  There  is  not  a  chapter 
in  the  book  which  has  not  been  revised  and  the  attempt  made  to 
bring  it  up  to  our  present  knowledge.  Entirely  new  chapters 
have  been  called  for  to  include  affections  until  recently  unknown, 


PREFACE    TO    THE    FOURTH    EDITION.  V 

and  the  greater  part  of  the  work  has  been  rewritten  from  our 
present  stand j)oint.  A  new  feature  of  this  edition  has  been  the 
introduction  of  chapters  upon  certain  diseases,  which,  although 
not  strictl}''  venereal,  are  liable  to  be  mistaken  for  such,  and  often 
come  under  the  care  of  the  venereal  specialist ;  we  refer  particu- 
larly to  affections  of  the  scrotal  organs  and  to  some  simple  affec- 
tions of  the  skin.  The  number  of  illustrations  has  been  largely 
increased.  It  will  be  seen  that  metric  weights,  as  well  as  the 
ordinary  troy  measures,  have  been  given  in  all  prescriptions;  and 
the  attempt  has  been  made,  though  confessedly  with  many  errors 
and  omissions,  to  follow  the  "Abbreviations  of  the  Titles  of  Peri- 
odicals," adopted  by  Dr.  Billings  in  the  Library  of  the  Surgeon- 
General's  Office. 

FEEEMAX  J.  BUMSTEAD. 

New  York,  Oct.  12,  1879. 


CONTENTS. 


Introduction 


I'AOB 

17 


PART   I. 


GONORRHOEA  AND  ITS  COMPLICATIONS. 


CHAPTER  I  — Urkthral  Gonorrhoea  in  the  Male 

Preliminary  cousideratious 

Symptoms  .         .  '       . 

Causes  and  nature  of  gonorrhoea 

Treatment  ..... 

Abortive  treatment     . 
Treatment  of  the  acute  stage 
Treatment  of  the  stage  of  decline 
Injections  ..... 
Copaiba  and  cubebs   . 
Expectant  treatment . 
Obstacles  to  success  of  treatment 
Treatment  of  special  symptoms 

CHAPTER  II.— Gleet 
Symptoms 
Pathology 
Treatment 

Bougies 

Applications  by  means  of  the  endoscope 

Injections  ..... 

Deep  urethral  injections     . 

Blisters      ..... 

Separation  of  the  affected  surfaces 


CHAPTER  III.— Balanitis 
Causes 
Symptoms 
Complications  . 
Diagnosis 
Treatment 

CHAPTER  IV.— Phimosis 
Congenital  phimosis 
Accidental  phimosis 
Treatment 

Circumcision 


35 
35 
36 
40 
47 
48 
58 
56 
57 
63 
71 
73 
74 

78 
80 
81 
82 
84 
87 
91 
93 
95 
96 

97 
97 
98 
99 
100 
101 

104 
104 
106 
107 
110 


CONTENTS. 


CHAPTER  v.— Paraphimosis 

Treatment  ......... 

CHAPTER  VI  — Folliculitis  and  Peri-Urethral  Phlegmon 
Folliculitis         ......... 

Peri-urethral  phlegmon     ....... 

CHAPTER  VII. — Inflammation  of  Cowper's  Glands     . 

CHAPTER  VIII. — Affections  of  the  Corpora  Cavernosa    . 
Chronic  circumscribed  iuflanimation  of  the  corpora  cavernosa 


CHAPTER  IX — Lymphangitis  and  Adenitis 
Lymphangitis   .  , 

Adenitis    .... 

CHAPTER  X.— Swelled  Testicle 
Causes 
Seat 

Symptoms 

Pathological  anatomy 
Treatment 

Sedatives  . 

Pulsatilla  . 

Blood-letting 

Ice     . 

Poultices   . 

Strapping  the  testicle 

Antimonial  frictions 

Solution  of  nitrate  of  silve 

Punctures . 

Iodoform    . 
Induration  of  the  epididymis 

CHAPTER  XL— Hydrocele  . 

Treatment 

Congenital  Hydrocele   . 

Encysted  Hydrocele  of  the  Testis 

Hydrocele  of  the  Spermatic  Cord 

CHAPTER  XII.— Hematocele 
Hematocele  of  the  Testis 
Hematocele  of  the  Cord 

CHAPTER  XIIL— Varicocele 

Treatment         ..... 

CHAPTER  XIV. — Gonorrhceal  Prostatitis 

Acute  Prostatitis  . 

Symptoms 

Treatment 

Chronic  Prostatitis 

Treatment 


CONTENTS.  IX 

PAGE 

CHAPTER  XV  — Ctstitis 178 

Treatment         .         .         • ■  .         .         .180 

CHAPTER  XVI. — Inflammation  of  the  Vesicul.e  Seminalks        .         .         .  182 

CHAPTEPi  XVII. — Gonorrhceal  Pepitonxtis  and  Sub-peritoneal  Abscess 

IN  THE  Male          ...........  184 

CHAPTER   XVIII  — GONORRHCEA  IN  AVOMEN 186 

Causes 186 

Symptoms 188 

Gonorrhoea  of  the  vulva      .........  189 

Gonorrhoea  of  the  vagina  .........  193 

Gonorrhoea  of  the  uterus   .........  195 

Gonorrhoea  of  the  urethra           ........  1(»7 

Complications  ............  199 

Vegetations        .         .         .         .         .  .         .         .         .         .         .199 

Ovaritis     ............  199 

Diagnosis           ............  2OO 

Treatment         ............  2OI 

Blood-letting      ...........  201 

Batos  and  lotions        ..........  201 

Sedatives  ............  202 

Injections  ............  202 

Separation  of  the  diseased  surfaces   .......  20-5 

Hip-baths ............  206 

"Latent  GoNORRHCEA  TN  Women" 209 

CHAPTER  XIX. — GoNORRHOBA  OF  the  Rectum,  Nose,  and  Umbilicus     .         .211 

GoNORRHCEA  OF  the  Rectum      .........  211 

Treatment           ...........  212 

GONORRHCEA  OF  THE   MoUTH          .........  212 

GoNORRHCEA  OF  the  Nose          •••......  213 

Umbilical  Gonoerhcea     ..........  213 

CHAPTER  XX. — Gonorrhceal  Ophthalmia 214 

Frequency         ............  214 

Causes      .         .         .         .         .         .         .         .         .  •         .         .         .215 

Symptoms         ............  217 

Diagnosis           ............  220 

Treatment         ••••........  220 

CHAPTER  XXI. — Gonorrhceal  Rheumatism .  227 

Causes 229 

Frequency 230 

Seat ■    ....  231 

Symptoms 233 

Diagnosis           ............  237 

Treatment         ............  239 

CHAPTER  XXII.— Vegetations 242 

Treatment 244 


CONTENTS. 


CHAPTER  XXIII.— Herpes  Phogenitalis      . 
Treatment         .         .         .   •      . 

CHAPTER  XXIV. — Strictuee  of  the  Urethra 
Anatomical  Considerations    . 
Strictures       .... 
Spasmodic  stricture  . 
Permanent  or  organic  stricture 

Seat   .... 

Number 

Form  .... 

Degree  of  contraction 
Pathology  of  stricture 

Abscess  and  fistula 

Bladder 

Ureters  and  kidneys    . 

Genital  organs    . 
Symptoms  of  stricture 
Causes  of  stricture    . 
Diagnosis  of  strictures 
Exploration  of  the  urethra 

Shape  and  size  of  metallic  instruments 

Catheters    . 

Sounds 

Bougies 

Acorn-pointed  sounds  and  bougies 

Urethrometers    . 

Introduction  of  the  catheter 
Treatment  of  strictures 

Constitutional  means  . 

Dilatation    . 

Continuous  dilatation 

Over-distention  . 

Internal  incision 

Rupture 

Caustics 

External  perineal  urethrotomy    . 
Consequences  of  operations  on  strictures 

Hemorrhage        .... 

Curvature  of  the  penis 

Urethral  fever     .... 
Treatment  of  retention  of  urine 

I'uncture  by  the  rectum 

Puncture  above  the  pubes  . 

Puncture  through  the  symphysis 

Opening  the  urethra  posterior  to  the  stricture 
Treatment  of  extravasation 
Treatment  of  urinary  abscess  and  fistula 
Proposed  set  of  urethral  instruments 


CHAPTER  XXV.— Sexual  Hypochondriasis 


332 


CONTENTS. 


PART   II. 


THE  CHANCROID  AND  ITS  COMPLICATIONS. 


CHAPTER  I. — The  Chancroid  or  Simple  Chancre 
The  chancroidal  poison 
Contagion 

Frequency  of  the  chancroid 
Seat  of  the  chancroid 
The  chancroid  from  inoculation 
The  chancroid  from  contagion 

Development 

Period  of  progress     . 

Stationary  period 

Reparative  stage 
Number  of  chancroids 
Varieties  of  the  chancroid 
Diagnosis  of  the  chancroid 
Prognosis  of  the  chancroid 
Pathological  anatomy 
Treatment  of  the  chancroid 

General  treatment 

Abortive  treatment    . 

Destructive  cauterization 

Local  applications 


PAGE 

839 
339 
343 
346 
348 
351 
352 
852 
354 
355 
356 
357 
358 
359 
363 
363 
365 
365 
365 
,  366 
,     369 


CHAPTEFv  II. — Peculiarities  Dependent  dpon  the  Seat  of  Chancroids 
Chancroils  upon  the  Integument  of  the  Penis 
Chancroids  of  the  Fr^num     . 
Sub-Preputial  Chancroids 
Urethral  Chancroids     .... 
Chancroids  of  the  Female  Genital  Organs 
Chancroids  of  the  Anus  and  Rectum 


CHAPTER  III.— The  Chancroid  Complicated  with  E 
TiON  and  with  Phagedena  . 
Inflamjiatory  OK  Gangrenous  Chancroid 
Phagedenic  Chancroid    .... 
Serpiginous  chancroid 
Sloughing  phagedenic  chancroid 
Treatment  of  phagedaena  . 


XCESSIVE     InFLAMMA- 


373 
373 
373 
374 
376 
377 
381 


383 
383 
385 
385 
38G 
387 


CHAPTER   IV. — The    Chancroid    Complicated    with    Syphilis. — "  Mixed 

Chancre" 390 


CHAPTER  v.— The  Simple  and  Virulent  Bubo 394 

Frequency  of  buboes  .........  394 

Seat  of  buboes  ...........  395 

The  Simple  Bubo 397 


XU  CONTENTS. 

PAGE 

The  Virulent  Bubo         ..........  'iW 

Complications    .....          ......  404 

"  Bubon  d'embl6e"    ..........  405 

Diagnosis  of  buboes  ..........  406 

Treatment  of  buboes         ..........  407 

Abortive  measures      ..........  408 

Methods  of  opening  buboes        .         .         .         .         .         .         .         .410 

CHAPTER  VI.— Ltmphitis 416 

Simple  Lymphitis    .         .         .         .         .         .         .         .         .         .         .416 

Virulent  Lymph]tis        ..........     416 


PART  III. 

SYPHILIS. 

CHAPTER  I. — Introductory  Remarks 419 

Syphilitic  Virus      .         .         .         .         .         .  .         .         .         .419 

Syphilis  commonly  occurs  but  once  in  the  same  Person       .         .         .  420 

Syphilis  possesses  a  period  of  Incubation     ......  423 

The  Order  of  Evolution  of  Syphilitic  Symptoms,  and  the  Classifica- 
tion founded  thereon  .........  423 

The  Sources  of  Syphilitic  Contagion    .......  429 

The  Modes  of  Syphilitic  Contagion       .......  432 

General  Syphilis  always  follows  a  Chancre         .....  484 

Syphilis   pursues   essentially   the    same    course,    whethf.r  dkrived 
from  a  Primary  or  Secondary  Lesion  ;   in  the  latter  case,  as  in  the 

FORMER,  the  INITIAL  LESION  IS  A  CHANCRE        ......  436 

Syphilis  has  a  Second  Period  of  Incubation,  which,  although  subject 

TO  SOME  Variation,  is  not  Indefinite  in  its  Duration         .         .         .  437 

CHAPTER  II.— The  Nature  of  Syphilis 439 

CHAPTER  III. — The  Initial  Lesion  of  Syphilis,  or  Chancre      .         .         .  446 

Seat  of  chancres        ...........  445 

Incubation  of  the  chancre  .........  446 

Symptoms         ............  448 

Multiple  herpetiform  chancres    ........  450 

Anomalous  appearance        .........  450 

Infecting  balano-posthitis  .........  451 

Induration  of  the  chancre  .         .  ......  461 

Relapsing  induration  .........  466 

Secretion   ............  456 

Duration    ............  457 

Termination       ...........  457 

Number  of  chancres  .........  458 

Phagedsena 458 

Condition  of  neighboring  ganglia        . 459 

Diagnosis  of  the  chancre 459 


CONTENTS.  Xlll 

PAGE 

Pathological  anatomy 4(32 

Treatment 466 

Excision     ............  467 

General  treatment      ..........  469 

CHAPTER  IV.— Special  Indications  FROM  THE  Seat  OF  Chancres         .         .  471 

Chancres  of  the  Urethra       .........  471 

Chancres  of  the  Anus     ..........  472 

Extra-Genital  Chancres 473 

Chancres  of  the  Fingers        .........  473 

Chancres  of  the  Lips      ..........  474 

Chancres  of  the  Buccal  Cavity      ........  474 

Chancres  in  the  Female          .........  475 

Of  the  fourchette  and  the  vestibule    .......  47G 

Of  the  breast 477 

Of  the  uterus 478 


CHAPTER  V. — Induration  of  THE  Ganglia  AND  OF  the  Lymphatics     .         .  479 

Induration  of  the  Ganglia      .........  479 

Its  constancy      ...........  479 

Its  seat 481 

Time  of  its  appearance       .........  482 

Its  course  and  termination  ........  483 

Induration  of  the  Lymphatics        .......  485 

Treatment  of  induration  of  the  ganglia  and  lymphatics      .         .         .  486 

CHAPTER  VI.— State  OF  THE  Blood;  Stphilitic  Fever;  Affections  of  the 

Distant  Lymphatic  Ganglia         ........  487 

State  of  the  Blood  ..........  487 

Syphilitic  Fever     ...........  488 

Affections  of  the  Ganglia      .........  490 

Engorgement  of  the  superficial  ganglia      ......  490 

Deep  lymphatic  ganglia      .........  492 

CHAPTER  VII. — Cachexia,  Chloro-an^emia,  Asthenia         ....  493 

CHAPTER  VIII.— Influence  of  Syphilis  upon  the  Constitution  .         .  496 

Influence  of  Syphilis  upon  Dibea.ses  in  General  .....  498 

On  acute  diseases       .         .  .         .  .         .         .         .         .         .  498 

On  chronic  diseases    ..........  498 

Influence  of  Syphilis  upon  Traumatism  ......  500 


CHAPTER  IX.— Prognosis  of  Syphilis 


502 


CHAPTER  X. — Irritability  of  the  Skin  and  Mucous  Membranes.    Changes 

in  the  Sensibility  of  the  Skin    ........     507 


CHAPTER  XL— The  Syphilides     . 
General  remarks  upon 
Their  course 

Absence  of  itching  and  pain 
Polymorphism    . 
Color  and  pigmentation 
Tendency  to  assume  a  circular  form 
lufluence  of  mercury 


509 
509 
511 
511 
512 
512 
512 
513 


XIV 


CONTENTS. 


Influence  of  intercurrent  diseases  on  the  course  of  s 
Unusual  modes  of  evolution 
The  localization  of  the  syphilides 
Characters  of  the  scales  and  crusts 
Peculiarities  of  ulcers  and  cicatrices 
Odor  of  certain  syphilitic  lesions 
General  hints  in  diagnosis  . 
The  Erythematous  Syphilide 

Coexisting  lesions  and  symptoms 
Diagnosis  ..... 
The  Papular  Syphilides 

The  miliary  papular  syphilide    . 
The  lenticular  papular  syphilide 
The  small  flat  papular  syphilide 
Mode  of  distribution  . 
Coexisting  symptoms  and  lesion 
Diagnosis    . 
The  large  flat  papular  syphilide 
Prognosis   . 
Diagnosis    . 
Scaling  papular  syphilide  of  the  palms  and  sole 
The  Pustular  Syphilides 

The  acne-form  syphilide     . 
Prognosis    . 
Diagnosis    , 
The  variola-form  syphilide 
The  impetigo- form  syphilide 
The  ecthyma-form  syphilide 
Rupia         .... 
The  Bullous  Syphilide  . 
The  Tubercular  Syphilide     . 
Diagnosis  .... 
The  Gummous  Syphilide 
The  Serpiginous  Syphilide    . 
The  Pigmentary  Syphilide     . 
Malignant  Precocious  Syphilides 
Spontaneous  Gangrene  in  the  Course  of  Syphilis 
Local  Treatment  of  the  Syphilides 


philides 


page 
513 
514 
514 
514 
515 
515 
516 
516 
518 
519 
520 
520 
522 
522 
522 
525 
525 
525 
528 
528 
529 
631 
632 
533 
533 
634 
536 
638 
641 
643 
544 
548 
549 
555 
568 
559 
562 
563 


CHAPTER  XII. — Cutaneous  Hemorrhage  in  Syphilis. 


507 


CHAPTER  XIII. — Certain  Simple  Cutaneous  Affections  of  the  Genitals 
Eczema  of  the  Scrotum  and  Penis 
Tinea  Circinata  Inguinalis    . 
Scabies    ...... 

Phtheiriasis  Pubis 

Tinea  or  Pityriasis  Versicolor     . 

Lupus  Erythematosus  of  the  Penis 


509 
669 
570 
671 
572 
573 
675 


CHAPTER  XIV. — Affections  of  the  Appendages  of  the  Skin 
Affections  of  the  Hair  ....... 

Affections  of  the  Nails         ...... 


570 
570 
578 


CONTENTS.  XV 

PAGE 

CHAPTER  XV. — General  Remarks  upon  Affections  of  Mucous  Membranes  583 

Erythema         ............  683 

Mucous  Patches      ...........  584 

Treatment 589 

CHAPTER  XVI. — Affections  of  the  Organs  of  Digestion  ....  591 

The  Mouth 591 

Erythema 591 

Mucous  patches  .         .         .  .         .         .         .  .         .         .591 

Papules  and  vesicles           .         .         .         .         .         .         .         .  •      .  591 

The  Tongue 592 

Sclerosis    ............  593 

Superficial           ..........  593 

Deep 593 

Gummata            ...........  593 

Superficial           ..........  593 

Deep  .         .         .         .         .         .      • 593 

Sublingual  Gland  ...........  595 

Necrosis  of  the  Maxillary  Bones          .......  595 

Gummy  Tumor  on  the  Soft  Palate           .......  590 

The  Pharynx 598 

Treatment  of  Lesions  of  the  Mouth  and  Pharynx        ....  599 

The  (Esophagus 601 

Stomach  and  Intestines           .........  603 

The  Rectum     ............  605 

The  Liver 609 

Chronic  interstitial  hepatitis      ........  .609 

Gummata            ...........  610 

Amyloid  degeneration        .         .         .         .         .         .         .  .  .611 

The  Spleen              612 

Enlargement      .         .         .         .         .         .         .         .         .         .         .612 

Gummata 613 

The  Pancreas          ...........  614 

CHAPTER  XVII. — Affections  of  the  Organs  of  Respiration      .         .         .  615 

The  Nose 615 

Treatment  of  lesions  of  the  nose         .......  616 

The  Larynx 616 

Erythema 619 

Superficial  ulcerations        .........  619 

Mucous  patches         .....  .....  620 

Deep  ulcerations        ..........  621 

Gummy  tumors  ..........  622 

Perichondritis  ...........  622 

Caries 622 

Syphilitic  aphonia 623 

The  Trachea  ............  623 

Treatment  of  lesions  of  the  larynx  and  trachea  .....  624 

The  I'.ronchi 625 

The  Lungs 626 

Interstitial  pneumonia        .........  626 

Gummy  tumors  ..........  626 


XVI  CONTENTS. 

PAGE 

CHAPTER  XVIII. — Affkctions  of  thr  Organs  of  Circulation     .         .         .  6^0 

The  Heart       ............  630 

The  Bloodvessels 631 

CHAPTER    XIX. — SECONrMRY  and   Tertiary  Affections  of  the  Genito- 
urinary Organs 633 

Syphilitic  Epididymitis  .         .         .         .         .  '       .         .         .         .         .  633 

Syphilitic  Orchitis         . 633 

Symptoms          ...........  634 

Pathological  anatomy         .........  635 

Diffused  form      .....          .....  636 

Circumscribed  form    .........  636 

Diagnosis 636 

Treatment 638 

Affections  of  the  Vasa  Deferentia  the  Vesicul^  Seminai.es,  and  the 

Prostate       ...........  638 

Affections  of  THE  Penis          .........  639 

Affections  of  the  Ovaries.  Fallopian  Tubes,  Uterus,  and  Vagina       .  640 

Exulcerative  hypertrophy  of  the  neck  of  the  uterus     ....  640 

Affections  of  the  Kidneys     .         ........  641 

Interstitial  nephritis           .........  641 

Gummy  tumors          .         .          ........  642 


CHAPTER  XX — Affections  of  the  Nervous  System 
Predisposing  causes  . 
Affections  of  the  Neighboring  Bones 
Affections  of  the  Dura  Mater 
Affections  of  the  Arachnoid  and  Pia  Mater 
Affections  of  the  Brain  and  Cord 
Affections  of  the  Arteries    . 
Affections  of  the  Nerves 
Cerebral  Syphilis  sine  Materia 
Prodromal  Symptoms 
Syphilitic  Tumors  of  the  Nervous 
Meningeal  Symptoms 
Syphilophobia 

Hemiplegia      .... 
Syphilitic  Epilepsy 
Syphilitic  Paraplegia    . 
Aphasia  ..... 
Locomotor  Ataxia  . 
Chorea    ..... 
Pseudo-general  Paralysis 
Treatment 


System 


643 

644 
644 

645 

645 

646 

640 

649 

651 

651 

653 

654 

656 

656 

658 

659 

660 

661 

661 

6f51 

662 


CHAPTER  XXL  — Syphilitic  Affections  of  the  Muscles  and  their  Acces- 
sories   ............  664 

Diffuse  form.     Muscular  contraction  .......  664 

Muscular  tumors        .........;  666 

Contraction  of  the  jaws     .........  669 

Affections  of  the  Tendinous  Sheaths  and  of  the  Tendons  and  Aponeu- 
roses    ............  668 

Affections  of  the  Bues^e        .........  (J69 


CONTENTS. 


XVll 

PAGE 


CHAPTER  XXII. — Affections  OF  THE  Fingers  AND  Toes.    Dactylitis  Syrni- 

LITICA 671 


CHAPTER  XXIII. — Affections  of  the  Bones,  Cartilages  and  Joints 
Late  Osseous  Affections 

luflammatory  form.     Osteo-periostitis 
Exostoses  ..... 

Gummy  form.     Osteomyelitis    . 
Dry  caries  ..... 

Syphilitic  cicatrices  in  bone 
Treatment  ..... 

Affections  of  the  Cartilages 
Affections  of  the  Joints 

Arthralgia  ..... 

Synovitis   ...... 

Synovitis  of  the  early  stage 
Synovitis  of  the  late  stage 


CHAPTER  XXIV.— Affections  of  the  Eyes 
Affections  of  the  Bones  of  the  Orbit  . 
Affections  of  the  Lachrymal  Passages 
Affections  of  the  Lachrymal  Glanu 
Affections  of  the  Eyelids     . 

Syphilitic  ulcerations 
Affections  of  the  Conjunctiva 
Affections  of  the  Cornea 
Affections  of  the  Sclera 
Syphilitic  Iritis   .... 
Simple  or  plastic  iritis 
Serous  iritis      .... 
Parenchymatous  or  suppurative  iriti 
Infantile  iritis    .... 
Spongy  iritis      .... 
Affections  of  the  Lens  . 
Affections  of  the  Ciliary  Body     . 
Choroiditis      ..... 
Plastic  choroiditis 
Serous  choroiditis 
Parenchymatous  choroiditis 
Retinitis  ..... 

Affections  of  the  Optic  Nerve 
Affections  of  the  Vitreous    . 
Paralysis  of  the  Nerves  of  the  Eye 
Hereditary  Syphilis  of  the  Eye    . 


CHAPTER  XXV.— Affections  OF  THE  Ear    . 

External  ear       ...... 

Middle  ear  ...... 

Internal  ear        ...... 

Sudden  Deafness  prouuckd  by  Syphilis 

Deafness  due  to  Syphilitic  Affections  of  the  Brain 

Diseases  of  the  Ear  in  the  Subjects  of  Congenital  Syphilis 

B 


CONTENTS. 


CHAPTER  XXVI.— Herkditakt  Syphilis      . 

The  Duration  and  Progress  of  Hereditakt  Syphilis 
The  Process  of  Procreation  . 

Influence  of  the  father 

Influence  of  the  mother 

Infection  of  the  child  at  birth 

Infection  by  the  semen  of  syphilitic  men 
Invasion  and  Evolution  of  Hereditary  Syphilis 
Eruptions  of  Hereditary  Syphilis 

The  erythematous  sypbilide,  or  roseola 

The  papular  syphilide  and  condylomata  lata 

The  vesicular  sypbilide 

The  pustular  syphilide 

Furuncular  eruptions 

The  bullous  syphilide — Pemphigus 

The  tubercular  syphilide    . 

Gummata  and  gummatous  ulcers 
Affections  of  the  Mucous  Membranes 

Mucous  patches  of  the  mouth     . 

Gummatous  infiltrations     . 
Affections  of  the  Larynx 
Affections  of  the  Lungs 
Affections  of  the  Peritoneum 
Affections  of  the  Alimentary  Canal 
Affections  of  the  Liver 
Affections  of  the  Spleen 
Lesions  of  the  Pancreas 
Affections  of  the  Kidney 
Affections  of  the  Supra-renal  Capsules 
Affections  of  the  Testicle 

Morbid  anatomy 
Affections  of  the  Synovial  Sheaths 
Affections  of  the  Nails — Onychia 
Affections  of  the  Hair  . 
Affections  of  the  Thymus  Gland    . 
Affections  of  the  Lymphatic  Ganglia 
The  Condition  of  the  Blood  . 
Lesions  of  the  Umbilical  Vein 
Affections  of  the  Circulatory  Organs 
Hemorrhagic  Syphilis  in  New-born  Children 
Affections  of  the  Bones 

Osteo-chondritis 

Periostitis  .... 

Dactylitis  syphilitica 

Swellings  of  the  metacarpal  and  metatarsal  bon 
Affections  of  the  Joints 
Affections  of  the  Nervous  System 
Treatment  of  Hereditary  Syphilis 

CHAPTER  XXVII. — Affections  of  the  Placenta 
Macroscopic  appearances  .... 
Microscopic  appearances  .  .  .  . 
Predisposing  causes  ..... 


CONTENTS. 

XIX 

PAGE 

CHAPTER  XXVIII.— Treatment  of  Syphilis 787 

Hygiene  and  Tonics         .... 

788 

Meecdkials      ...... 

790 

Fumigation        .... 

795 

Inunction 

798 

Mercurial  suppositories     . 

799 

Hypodermic  injections 

799 

Effects  of  Mercury        .... 

803 

Duration  of  treatment 

808 

Iodine  and  its  Compounds 

810 

Iodoform          

816 

Nitric  Acid  and  Gold     .... 

817 

Vegetable  Decoctions  and  Infusions 

817 

Tayuya      

818 

Balneotherapia       

818 

Climatic  Influences        .... 

820 

Syphilization 

820 

LIST  OF  ILLUSTEATIONS 


FIG. 
1. 

2. 
3. 
4. 
6. 
6. 


9. 
10. 
11. 
12. 
13. 
14. 
15. 
16. 
17. 
18. 
19. 
20. 
21. 
22. 
23. 
24. 
25. 
26. 
27. 
28. 
29. 
30. 
31. 
32. 
33. 
34. 
35. 
36. 
37. 
38. 
39. 
40. 
41. 
42. 


Urethral  syringe         .... 

Urethral  syringe,  No.  1,  A 

Hacker's  urethral  syringe 

"  Peerless  syringe"   .... 

Urethral  syringe  with  extra  long  pipe 

Otis's  cold-water  coil 

Urethral  polypus       .... 

Lacuna  magna  ..... 

Cupped  sound  ..... 

Griinfeld's  endoscopic  tubes 

Swab-holder      ..... 

Blower  and  pencil  for  local  applications 

Scissors  for  removal  of  polypi   . 

Forceps  for  urethral  polypi 

D^sormeaux's  endoscope  . 

The  same  modified  by  Denis 

Endoscope  with  gaslight  attachment 

Prof.  Auspitz's  dilating  urethroscope 

Dick's  catheter-syringe 

Guyon's  injector        .... 

Bumstead's  syringe  for  deep  injections 

Tiemann's  "  universal  sj'ringe". 

Gangrene  of  prepuce,  with  glans  penis  button-holed 

Nelaton's  phimosis  forceps 

Taylor's  phimosis  scissors  and  syringe 

Henry's  phimosis  forceps  . 

Operation  of  circumcision 

Horteloup's  forceps  for  the  flaps 

Head  of  penis  after  first  incision 

Method  of  introducing  sutures  . 

Paraphimosis    ..... 

"  Sub-preputial  frill" 

Method  of  reducing  .... 

Follicular  abscess  of  urethra     . 

Abscess  on  one  side  of  friBnum 

Abscess  divided  by  frrcnum  into  two  lobes 

Abscess  at  peno-scrotal  angle    . 

Vertical  section  of  testis  and  epididymis 

Miliano's  compressive  suspensory 

Morgan's  suspender  for  varicocele     . 

Weir's  varicocele  spring     . 

Henry's  scrotal  clamp 


PAGE 

48 
49 
40 
49 
50 
75 
81 
82 


88 

88 

88 

88 

89 

89 

90 

91 

93 

94 

94 

94 

99 

108 

109 

110 

110 

111 

112 

112 

114 

115 

116 

121 

122 

122 

123 

140 

150 

]t;5 

1(16 
168 


LIST    OF    ILLUSTRATIONS. 


48, 

44. 

45. 

46. 

47 

48. 

49. 

50. 

51. 

52. 

53. 

54. 

55. 

56. 

57. 

58. 

69. 

60. 

61. 

62. 

63. 

64. 

65. 

66. 

67. 

68. 

69. 

70. 

71. 

72. 

73. 

74. 

75. 
76. 
77. 
78. 
79. 
80. 
81. 
82. 
83. 
84. 
85. 
86. 
87. 
88. 
89. 
90. 
91. 
92. 
93. 
94. 
95. 
96. 
97. 


etc. 


,  Sebaceous  vulvitis 
Inflamed  vulvo-vaginal  gland 
Foster's  vaginal  douche     . 

t  Ophthalmic  gonorrhoea    . 

Collyrium-dropper    . 
Bladder  and  urethra  laid  open 
Fossa  navicularis  with  lacuna  magna 
Vertical  section  of  pelvis  showing  fasciie  . 
Horizontal  section  of  pelvis  showing  fascise 
Buck's  fascia     ...... 

Vertical  section  of  bladder,  penis  and  urethra 

Thompson's  diagram  showing  seat  of  strictures 

Annular  stricture 

Tortuous  stricture 

Strictures  near  meatus 

Diagram  showing  curves  of  sounds, 

Charrifere-filiere 

Millimetre  gauge 

Handerson's  catheter  gauge 

Compound  male  and  female  catheter 

Jaques's  catheter 

Olis's  prostatic  guide 

Prostatic  catheter 

Squire's  vertebrated  catheter    . 

French  flexible  bougie  and  catheter 

Fine  whalebone  bougies    . 

Acorn-pointed  sounds 

Curved  acorn-pointed  sounds 

Acorn-pointed  bougies 

Meatometer       .... 

Pilfard's  *'  fossal  bougies  a  boule" 

Otis's  urethrometer  . 

Weir's  urethrometer  ... 

First  step  in  introducing  catheter 

Second  step  in  introducing  catheter 

Thompson's  instrument  for  over-distention 

Canulated  staff. 

Filiform  bougie  with  screw-head 

Bumstead's  tine  catheter  with  filiform 

Civiale's  concealed  bistoury 

Meatotome 

Dick's  sonde-tourniquet     . 

1 


Sections  of  the  penis  showing  position  of  the  urethra  in  the  corpus  spon- 


-bougie  attachment 


giosum 


J 

Bumstead'e  modification  of  Maisonneuve's  urethrotome 

Voillemier's  urethrotome  . 

Otis's  dilating  urethrotome.  No.  3 

Otis's  dilating  urethrotome,  No,  4 

Civiale's  urethrotome 

Holt'a  rupture-instrument  modified 


LIST    OF    ILLUSTRATIONS. 


FIO. 

98. 

99. 
100. 
101. 
102. 
103. 
104. 
105. 
106. 
107. 
108. 
109. 
110. 
111. 
112. 
113. 
114. 
115. 
116. 
117. 
118. 
119. 
120. 
121. 
122. 
128. 
124. 
125. 
126. 
127. 
128. 
129. 
130. 
131. 
132. 
133. 
134. 
135. 
13G. 
137. 
138. 


Voillemier's  rupture-instrument 

Syme's  staflF    ..... 

Mode  of  cutting  on  staff 

Grooved  staflF  with  button-like  end  . 

Teale's  probe-gorget 

Wheelhouse's  operation    . 

Tapping  the  urethra  in  the  perinreum 

Otis's  perineal  tourniquet 

Thompson's  "probe-pointed  catheter" 

Dieulafoy's  aspirator 

Potaia's  aspirator    .... 

>•  Trocar  and  canula  for  puncture  of  the  bladder 

Recto-vesical  and  supra-pubic  puncture  . 

Section  of  a  chancroid     ..... 

Skeene's  urethroscope      ..... 

Auspitz's  diagram  showing  position  of  inguinal  ganglia 

Phagedenic  bubo      .... 

Section  of  a  chancre 

Section  of  an  artery,  vein,  and  a  lymphatic  in  induration 

Similar  sections  showing  obliteration  of  artery  and  vein 

Vegetating  condylomata  about  the  vulva 

Pharyngeal  atomizer 

Sj'philitic  affection  of  cerebral  arteries 

Dactylitis  of  second  toe  . 

Dactylitis  of  finger 

Dactylitis  of  finger 

Dactylitis  of  finger  .         . 

Dactylitis  of  finger 

Gummata  of  head  and  face 

Syphilitic  papule  of  conjunctiva 

|-  "Hutchinson's  teeth"  . 

Gummy  tumor  of  sclera  . 
Section  of  the  same 

t  Case  of  dactylitis  from  hereditary  taint 

Case  of  dactylitis  from  hereditary  taint 
Case  of  dactylitis  from  hereditary  taint 
Lee's  latest  lamp  for  fumigation 
Maury's  apparatus  for  fumigation    . 


PAGE 

311 
813 
314 
315 
315 
315 
317 
319 
322 
325 
325 

326 

327 
364 
377 
896 
403 
462 
464 
465 
587 
600 
632 
672 
673 
674 
675 
676 
682 
697 

700 

706 
707 

771 

772 
773 

796 
797 


ERRATA. 

Pagfe  117,  ]7tli  line  from  top, /or  "  Badinet,"  read  "Bardinet." 

"  "     19lli  Hue  from  top,/t>r  "Foiirneaux,"  read  "FurLieaux." 

"  16.J,  ]-tth  line  from  top, /or  "ductor,"  read  "  dartos." 

"  2.58,  7th  line  from  bottom,  for  "  pubis,"  read  ''  pubes." 

"  306,  llth  line  from  top, /or  "93,"  rertd  "92." 

"  431,  12th  line  from  top, /or  "Pellizari,"  read  "Pellizzari." 

"  567,  loth  line  from  top, /or  "  ultra,"  read  "  intra." 

"  743,  foot-note, /or  "  Spath,"  read  ''  Spilth." 

"  75S,  8th  line  from  bottom, /or  "  Rocliebonne,"  read  "  Eochebrune. 

"  763,  13th  line  from  bottom,  omit  "areata"  after  "  alopecia." 

"  764,  11th  and  16th  Hues  from  top,.A'r  "Weisflag,"  read  "Weisflog 
"        "    11th  Hue  from  top, /or  "Wiederhofeu,"  read  "  Wiederhofer." 


YENEREAL  DISEASES. 


INTRODUCTION. 

Yenekeal  Diseases,  so  called  from  their  most  frequently  originating 
in  the  pleasures  of  Venus,  are  the  following : — 

I.    GONORRIKEA. 

II.  The  Chaxcroid. 
III.  Syphilis. 

Other  affections  may  indeed  be  contracted  in  sexual  intercourse,  but 
those  above  mentioned,  which  depend  more  exclusively  upon  this  mode  of 
origin,  and  which  are  commonly  recognized  as  The  Venereal  Diseases,  will 
form  the  subject  of  the  present  work. 

The  distinct  nature  of  these  three  diseases,  and  especially  of  the  latter 
two,  has  not  always  been  admitted,  and  still  finds  opponents.  Many 
volumes  have  been  written  and  much  bitter  controversy  indulged  in  by 
the  advocates  of  either  side. 

In  the  earlier  editions  of  this  work,  this  subject  received  considerable 
space  and  attention.  Indeed,  ours  was  the  first  comprehensive  treatise 
upon  Venereal  diseases,  published  in  any  language,  in  which  the  distinct 
nature  of  the  Chancroid  and  .Syphilis,  so  ably  advocated  by  Bassereau, 
was  made  the  basis  of  the  work ;  and  we  have  reason  to  believe  that  to 
the  satisfactory  manner  in  wliich  this  new  theory  explained  many  facts 
before  obscure,  was  to  be  attributed  the  favorable  reception  of  our  earlier 
efforts. 

In  the  present  edition  we  do  not  intend  to  enlarge  upon  this  question ; 
we  shall  on  the  contrary  curtail  or  omit  much  that  we  have  said  before. 
"We  must  reserve  our  space  for  the  many  practical  points  which  have  been 
accumulating  during  the  last  ten  or  fifteen  years,  and  which  are  now  en- 
grossing tlie  thouglits  of  those  interested  in  Venereal.  We  claim  that  the 
distinct  nature  of  the  Chancroid  and  Syphilis  is  a  question  already  settled 
in  the  affirmative,  as  recognized  absolutely  by  the  great  majority  of  the 
)>rofession,  and  as  recognized  practically  by  all  with  a  few  rare  exceptions. 
Dr.  Frederick  Zinsser,'  in  an  admirable  review  of  this  subject,  makes  the 

'  The  Doctrines  of  Unicism  and  Dualism  of  the  Syphilitic  Contagion,  Am.  J. 
Syph.  and  Derm.,  N.  Y.,  vol.  i,  1870,  p.  238. 
2 


18  INTRODUCTION. 

f'ollowina;  ti'iie  remark :  So  simply  and  naturally  the  dovhle  contagion  ex- 
plains tJic  different  forms  (of  venereal  disease),  that  even  after  the  fall  of 
dualism,  should  that  event  occur,  clinically  the  differentiation  would  be 
perpetuated. 

Wishing  to  fill  our  book  with  living  issues,  we  shall,  for  the  most  part, 
leave  dead  ones  buried,  contenting  ourselves  with  a  brief  history  of  their 
lives  for  the  benefit  of  our  junior  readers.  There  is  only  one  point  upon 
which  we  shall  somewhat  enlarge  on  account  of  its  comparative  novelty. 
We  shall  endeavor  to  establish  the  fact  that  not  only  is  the  chancroid 
distinct  fi'om  sy[)hilis,  but  that  it  possesses  no  specific  virus  of  its  own,  and 
that  it  may  arise  independently  of  contagion,  from  the  inoculation  of  the 
products  of  simple  inflammation.  We  would  thus  make  it  a  strict  congener 
of  gonorrhoea. 

History  of  Venereal  Diseases. 

GoxoRRiKEA Gonorrhoea  has  existed  among  all  nations,  and  from  the 

earliest  times  of  which  we  have  any  record.  It  is  clearly  referred  to  by 
Moses  in  the  15th  chapter  of  Leviticus,  where  he  lays  down  rules  for  the 
government  of  those  who  are  affected  witli  "a  I'unning  issue  out  of  the 
flesh." 

Among  the  Greeks  and  Romans,  gonorrhoea  appears  to  have  been  less 
common  than  among  the  Hebrews;  still,  unquestionable  traces  of  it  are 
found.  Hippocrates  describes  five  kinds  of  leucorrhoea,  in  addition  to  dis- 
charges dependent  upon  inflammation  of  the  womb,  which  are  mentioned 
separately.  Herodotus  states  that  "the  Scythians  made  an  irruption  into 
Palestine  and  pillaged  the  temple  of  Venus  Urania.  The  angry  Goddess 
sent  upon  them  and  their  posterity  the  woman's  disease,  which  is  charac- 
terized by  a  running  from  the  penis.  Those  attacked  by  it  are  looked  upon 
as  accursed."'  Celsus^  was  also  acquainted  with  balanitis  and  gonorrhoea; 
the  latter  dependent,  as  he  supposed,  upon  an  ulcer  within  the  urethra ; 
and  Cicero  says  that  "incontinence  gives  rise  to  dysuria,  in  the  same 
manner  that  hi";h  living  causes  diarrhoea." 

At  subsequent  periods,  this  disease,  and,  in  many  instances,  its  compli- 
cations of  swelled  testicle  and  cystitis,  were  described  with  more  or  less 
detail  by  Mesne*  in  904;  by  Haly  Abbas,*  one  of  the  Persian  magi,  who 
followed  the  doctrines  of  Zoroaster  and  wi'ote  in  980 ;  by  Rhazes,^  a  learned 
Arabian  physician,  born  in  Chorosana  in  852;  by  Albucasis,^  another  Ara- 
bian of  the  eleventh  century;  by  Constantine  of  Carthage;''  by  Micliael 
Scott*  in  1214;  by  Gariopontus  of  Salerno;  by  Rogerius,  Jolin  Gaddesden^ 

'  Clio,  lib.  i.  2  j)g  Medicina,  book  vi,  chap.  18. 

3  Siimm.  iii,  part  4,  sect.  i. 

4  De  Virgse  Passionibus,  Causis  eorum  et  Signis,  book  ix,  chap.  28. 

5  Rhazes,  book  x,  chap.  3. 

6  Theoric.  nee  non  Practic,  tract,  xxi,  fol.  92  et  93. 

7  Constantinus  Africaiius  :  De  Morboruni  Cognitione  et  Curatione,  lib.  v. 

8  Michael  Scott:  De  Procreat.  Horn.  Physion.,  cap.  vi. 

s  John  Gadclesden  :  Rosa  Anglica,  Practica  Medicinte,  a  Capite  ad  Pedes,  lib. 
ii,  c.  xvii,  fol.  107. 


HISTORY"    OF    VENEREAL    DISEASES.  19 

of"  England  (commencement  of  fourteeth  century) ;  John  de  Concoregio,^ 
John  Arculanus,  Guy  de  Chauliac,^  Valescus  de  Tarento,  John  Ardern,^ 
settled  at  London  in  1371  ;  and  by  many  othei's.  Since  the  close  of  the 
fifteenth  century,  when  the  study  of  venereal  diseases  received  new  impulse 
from  the  irruption  of  syphilis  into  Europe,  it  is  hardly  necessary  to  state 
that  every  medical  writer  has  been  familiar  with  the  existence  of  gonorrhoea. 

The  Chancroid A  contagious  ulcer  of  the  genital  organs,  presenting 

all  t]\e  symptoms  of,  and  undoubtedly  identical  with  the  ulcer  now  known 
as  the  chancroid,  has  also  existed  at  all  ages  Avhose  records  have  been  pre- 
served. Ulcers  of  the  genital  organs  and  suppurating  buboes  are  described 
by  nearly  all  the  Greek,  Latin,  and  Arabian  writers  on  medicine.  Hippo- 
crates gives  very  minute  directions  for  the  treatment  of  abscesses  in  the 
groin,  dependent  upon  ulcerations  of  the  womb  and  of  the  genitals.  Celsus 
is  still  more  explicit,  and  clearly  describes  the  simple,  phagedenic,  serpigi- 
nous, and  gangrenous  venereal  ulcers,  which  are  recognized  at  the  present 
day.  He  also  alludes  to  the  danger  of  destruction  of  the  prepuce  when  the 
ulcer  is  complicated  with  phimosis,  and,  under  such  circumstances,  advises 
circumcision.  Many  other  names  might  be  quoted,  but  it  is  unnecessary 
to  adduce  farther  evidence,  since  it  is  generally  admitted  that  ulcers  of  the 
genital  organs  dependent  upon  contagion  in  sexual  intercourse,  have  been 
known  from  a  very  remote  antiquity.  The  only  point  in  dispute  relates 
to  their  nature. 

It  is  maintained  by  some  authors,  and  especially  by  Cazenave,  that  these 
were  instances  of  primary  syphilis,  and  not  chancroids,  as  here  assumed; 
and  they  have  been  supposed  to  furnish  evidence  of  the  existence  of  syphilis 
in  Europe  prior  to  the  close  of  the  fifteenth  century.  This  idea  is  inad- 
missible for  several  reasons.  One  argument  against  it  is  the  frequency  of 
suppurating  buboes  with  which  these  ulcers  are  said  to  have  been  attended, 
since  in  the  great  majority  of  true  chancres  the  inguinal  ganglia  which 
become  indurated  remain  entirely  passive;  while  the  chancroid,  on  the 
contrary,  is  frequently  accompanied  by  an  inflammatory  bubo  terminating 
in  suppuration.  This  consideration,  however,  will  have  no  weight  with 
those  who  do  not  allow,  in  cases  of  venereal  sores,  any  prognostic  value  to 
suppuration  of  the  inguinal  ganglia;  but  we  can  Avell  afford  to  waive  it  and 
base  our  argument  upon  the  fact  that  there  is  no  clear  record  in  history  of 
the  existence  of  the  general  symptoms  of  syphilis  prior  to  the  year  1494; 
that  the  ulcer  of  the  genitals  known  to  the  ancients  was  always  a  local 
affection,  and  never  followed  by  manifestations  at  a  distance  from  the  point 
of  contagion ;  that  rejjeated  outbreaks  of  the  disease  when  once  apparently 

'  Practica  nova  Medicinje  :  Lucidur,  tract,  iv,  fol.  (J6. 

2  Cyrurgia  Guidonis  de  Cliauliaco,  tract,  vi,  doct.  ii. 

3  Becket :  Pliilosoidi.  Trans.,  vol.  xxx,  p.  839. 

Most  of  tho  above  texts  have  been  derived  from  a  learned  work  written  in  the 
last  century  by  Gruner,  and  entitled:  Aidirodisiacus  sive  de  Lue  Venerea  in  duas 
Partes  divisiis,*iuariim  altera  coutinet  ejus  Vestigia  in  Veterum  Auctorum  Monu- 
luentis  obvia,  altera  tiuos  Aloysius  Luisiiius  temere  onusit  Scriptores,  Jena,  ITSt). 


20  INTRODUCTION. 

cured  (lid  not  occur;  that  hereditary  syphilis  was  unknown;'  and  finally, 
that  the  physicians  who  lived  at  the  close  of  the  fifteenth  century,  and  who 
were  perfectly  familiar  with  the  ulcers  in  question,  were  struck  with  horror 
and  amazement  at  the  appearance  at  this  time  of  a  disease  which  is  now 
known  to  have  been  syphilis  ;  confessed  that  they  had  never  seen  its  like 
before,  and  that  they  were  ignorant  of  its  nature  and  treatment ;  and  in 
their  treatises  upon  venereal  for  nearly  thirty  years  afterwards,  described 
this  and  the  former  disease  in  separate  and  distinct  chapters,  thus  showing 
that  they  did  not  entertain  the  least  idea  of  their  identity. 

Subsequent  to  the  latter  part  of  the  fifteenth  century,  we  must  follow  the 
history  of  the  chancroid  in  connection  with  that  of 

Syphilis According    to    the    most    reliable    contemporary   authors, 

syphilis  was  first  known  to  European  nations  from  its  appearance  in  Italy 
in  the  latter  part  of  the  year  1-194,  about  the  time  that  Charles  YIIl., 
King  of  France,  at  the  head  of  a  large  army,  entered  that  country  for  the 
purpose  of  taking  possession  of  the  kingdom  of  Naples,  to  which  he  laid 
claim  by  right  of  inheritance.  In  this  expedition,  which  was  at  first 
favored  by  the  Neapolitans  themselves,  Charles  left  Home  on  his  way  to 
Naples  Jan.  28,  and  was  received  in  the  latter  city  Feb.  21,  141)0."^  The 
Neapolitans  soon  became  restive  under  the  yoke  of  their  new  master,  and, 
assisted  by  the  forces  of  Ferdinand  of  Aragon,  under  the  leadership  of 
Gonsalvo  of  Cordova,  the  great  captain,  endeavored  to  expel  the  French 
from  Italy. 

Now,  although  the  new  disease  may  have  had  no  necessary  connection 
with  the  events  just  mentioned,  yet  the  latter  doubtless  favored  the  exten- 
sion and  exacei'bation  of  tlie  former  through  the  license  and  debauch  attend- 
ing large  bodies  of  troops,  and  subsequently  led  to  mutual  recrimination 
between  the  natives  and  the  invaders  respecting  the  origin  of  the  nudady; 
the  French  calling  it  "Mai  de  Naples,"  because  it  was  to  them  unknown 
before  the  Neapolitan  expedition,  and  the  Italians  ascribing  its  origin  to 
the  French,  and  calling  it  the  "French  disease." 

It  is  often  asserted  that  the  subsequent  extension  of  syphilis  was  due  to 
its  conveyance  to  their  homes  alter  the  close  of  the  war  by  the  troops 
Avhich  had  been  collected  upon  Italian  soil.  This  could  not,  however, 
have  been  the  sole,  nor  even  the  chief  mode  of  its  transmission  ;  since  the 
French,  on  their  return  from  Naples,  fought  the  battle  of  Fornovo,  July  G, 
1495,^  and  a  decree  of  Emperor  Maximilian  I.,  "  Contra  Blas[)liemos," 
promulgated  at  the  Diet  of  Worms,  August  7,  of  the  same  year,  includes 
among  the  evils  sent  as  a  punishment  against  the  prevailing  vice  of  blas- 
phemy, "  pnesertim  novus  ille  et  gravissimus  hominum  morbus,  nostris 
dicbus  exortus,  quem  vulgo  Malum  Francicum  vocant,  post  hominum  nie- 
moriam  inauditus,  sa^ve  grassatur,"*  thus  showing  that  syphilis  had  already 

»  Sypliilis  in  infants  at  tlie  breast  is  first  mentioned  by  Gasparcl  Torello  (1498). 
2  Gl'K'Ciardim,  lib.  i,  cap.  iv.  3  Gi'icciahdixi,  lib.  ii,  cap.  iv. 

*  GoLDAST.  Const.  Imp.  ii,  110. 


HISTORY    OF    VENEREAL    DISEASES.  21 

spread  so  widely  in  Germany  as  to  attract  general  attention  about  the 
time  that  the  French  left  Italy. 

The  testimony  of  other  authors  also  concurs  in  showing  that  syphilis 
rapidly  extended  in  the  course  of  a  few  years  over  the  gi*eater  part  of 
Europe,  and  pervaded  every  rank  of  society.  As  stated  by  John  Lemaire, 
a  poet  of  that  period  : — 

II  n'espargnoit  ne  couronne  ne  crosse. 

A  large  amount  of  evidence  is  adduced  by  Bassereau^  and  Chabalier^ 
in  support  of  the  fact  already  mentioned  that  syphilis  was  entirely  un- 
known in  Europe  prior  to  1494.  Its  connection  with  sexual  intercourse 
was  not  at  first  recognized,  and  many  attributed  it  to  the  evil  influences  of 
the  stars ;  and  altliough  a  few  endeavored  to  assimilate  it  to  certain  dis- 
eases of  ancient  times,  as,  for  instance,  to  the  "  asaphati"  of  the  Persians, 
the  mentagra  which  prevailed  at  Rome  under  Tiberius,  to  psoriasis,  ele- 
phantiasis, and  lepra,  yet  the  greater  portion  of  the  writers  of  that  period 
declared  that  it  was  entirely  new  in  the  world's  history,  and  all  confessed 
that,  so  far  as  their  own  experience  went,  they  had  never  seen  anything 
like  it. 

The  contagious  ulcers  of  the  genitals  which  were  known  prior  to  the 
latter  part  of  the  fifteenth  century,  were  called  "  caries,"  "  caroli,"  and 
"  taroli,"  and  the  first  of  these  terms  was  afterwards  applied  to  the  new 
disease,  which,  however,  was  distinguished  as  the  "  caries  gallica." 
Moreover,  in  the  works  of  Marcellus  Cumanus,  Alexander  Benedictus, 
Leonicenus,  Gaspar  Torella,  John  de  Vigo,  and  other  authors  who  wrote 
within  thirty  years  after  the  appearance  of  syphilis,  these  two  affections 
were  described  in  separate  chapters  with  many  of  the  distinguishing  feat- 
ures that  are  recognized  at  the  present  day.  Thus  John  de  Vigo  mentions 
the  induration  of  those  ulcers  which  are  followed  by  constitutional  symp- 
toms :  "  Cum  calositate  eas  circumdante  ;"  and  none  of  the  writers  of  this 
early  period,  when  speaking  of  the  French  disease,  make  any  allusion  to 
suppurating  buboes,  which  are  described  apart  and  referred  to  the  "caries 
non  gallica"  known  in  ancient  times.  An  exceedingly  accurate  descrip- 
tion is  also  given  of  the  cutaneous  eruptions,  the  nocturnal  pains,  the  bony 
tumors,  and  otlier  general  symptoms  of  sy[)hilis  ;  and  notice  is  taken  of  tlie 
fact  that  a  cure  is  in  most  cases  only  temporary,  and  that  the  disease  often 
returns.  Moreover,  the  early  writers  on  syphilis  believed  in  the  contagious- 
ness of  general  symptoms,  and  even  of  the  blood  of  infected  persons,  whicli 
has  recently  been  demonstrated  by  actual  experiment. 

OuiGix  OF  Syphilis  unknown None  of  the  theories  wiiicli  have  been 

julvanced  to  account  for  the  appearance  of  sy[)hilis  in  Europe  near  tlie 
close  of  the  fifteenth  century,  rest  upon  sufficient  data  to  entitle  them  to 
absolute  credence.     We  cannot  suppose  that  it  was  of  the  nature  of  an 

'   AfTections  do  la  poaii  syniptdiiiatiqucs  dc;  la  sypliilis,  Paris.  1852. 
2  Prouv(!S  liistori(|uo.s  do  la  plurality  dos  affoctious  ditos  veneriennes,  Tlibse  de 
Paris,  18(J0  (No.  52). 


22  INTRODUCTION. 

epidemic  and  due  to  atmospheric  influences,  since  it  is  expressly  stated  by 
those  wlio  witnessed  its  advent  that  it  did  not  suddenly  affect  large  num- 
bers of  persons  of  all  ages,  but  spread  from  one  to  another,  chiefly  attack- 
ing the  middle-aged  (the  very  class  most  exposed  in  sexual  intercourse), 
and  sparing  old  men  and  infants,  and  the  inhabitants  of  cloisters,  and 
that  it  advanced  from  Italy  as  a  centre,  and  occupied  several  years  in  ex- 
tending to  the  more  remote  countries  of  Europe.  Moreover  our  present 
knowledge  of  the  disease  enables  us  to  state  with  confidence  that  it  never 
appears  except  as  the  result  of  contagion. 

Supposed  Aniericcm  Origin — The  theory  which  has  met  with  the  most 
favor,  refers  the  origin  of  syphilis  to  America,  whence  Columbus  returning 
from  his  first  voyage,  landed  at  Barcelona,  in  Spain,  in  1493,  only  a  year 
before  the  appearance  of  the  disease  in  Italy.  According  to  Chabalier,  it 
was  stated  by  John  Baptist  Fulgosus,  Doge  of  Venice,  as  early  as  1509, 
that  a  new  disease,  communicated  only  by  coitus,  and  first  affecting  the 
genital  organs,  had  broken  out  in  Spain,  and  had  thence  been  transported  to 
Italy,  and  also  that  it  came  into  Spain  from  Africa  :  "  Qua?  pestis  primo 
ex  Hispania  in  Italiam  allata,  ad  Hispanos  ex  ^Ethiopia,  brevi  totum  ter- 
rarum  orbem  comprehendit."  The  idea  that  syphilis  was  brought  to 
Europe  from  America  by  the  sailors  under  Columbus  was  first  advanced 
by  Leonard  Schmans,  in  1518,  Ulrich  von  Hutten  in  1519,  and  Fracas- 
tori  in  1521. 

There  can  be  no  doubt  that  syphilis  existed  in  the  colony  founded  by 
Columbus  during  his  second  voyage,  but  whether  indigenous  to  the  West 
Indies,  or  brought  there  by  the  Spaniards,  is  unknown.  Washington 
Irving,  in  his  Life  and  Voyages  of  Columbus,^  says,  when  speaking  of  the 
colony  at  Isabella :  "  Many  of  the  Spainards  suffered  also  under  the  tor- 
ments of  a  disease  hitherto  unknown  among  them,  the  scourge,  as  was 
supposed,  of  their  licentious  intercourse  with  the  Indian  females ;  but  the 
origin  of  which,  whether  American  or  European,  has  been  a  subject  of 
great  dispute." 

Prof  Joseph  Jones''  has  written  an  able  and  interesting  article  on  syphi- 
lis among  the  Aborigines  of  this  country,  and  endeavors  to  demonstrate  its 
existence  at  that  very  early  period  by  the  skeletons  found  in  the  ancient 
burial  ])laces  in  Georgia,  Tennessee,  Kentucky,  Louisiana,  and  Mississippi. 
The  marks  of  syphilis  in  the  bones  exhumed  have  been  traced  by  Dr.  Jones 
from  the  valley  of  the  Cumberland  to  the  Gulf  of  Mexico. 

The  supposition  had  been  advanced,  tliat  these  bones  presented  merely 
"  traces  of  periostitis,"  Avhich  were  not  due  to  the  action  of  the  syphilitic 
poison,  because  "  it  is  uncommon  to  find  sliin-bones  of  adults  belonging  to 
races  clad  in  skins  and  with  the  lower  extremities  exposed,  in  which 
there  is  not  more  or  less  roughness  or  hyperostosis  along  the  tibial  shafts." 
So  far  from  these  evidences  of  the  action  of  syi)iiilis  being  mere  "  traces 
of  periostitis,  and  constituting  mere  roughness  or  hyi)erostoses  along  the 

'  Vol.  i,  book  vi,  chap.  xi. 

2  N.  Orl.  M.  and  S.  J.,  June,  1878. 


HISTORY    OF    VENEREAL    DISEASES.  23 

tibial  shafts,"  the  bones  ave  in  many  instances  thoroughly  diseased,  en- 
larged, and  thickened,  with  the  medullary  cavity  completely  obliterated 
by  the  effects  of  inflammatory  action,  and  with  the  sui-faces  eroded  in 
many  places.  These  erosions  resemble  in  all  respects  those  caused  by 
syphilis  and  attended  by  ulceration  of  the  skin  and  soft  parts  during  life. 
Furthermore,  the  disease  was  not  confined  to  the  "tibial  shafts  ;"  bones  of 
the  cranium,  the  fibula,  the  ulna,  the  radius,  the  clavicle,  the  sternum, 
and  the  bones  of  the  face  exhibited  unmistakable  traces  of  periostitis, 
ostitis,  caries,  sclerosis,  and  exostosis. 

That  these  diseases  were  not  due  to  mechanical  injury  or  to  exposure 
to  cold,  is  evident  from  the  fact  that  they  were  almost  universally  sym- 
metrical. Thus,  when  one  tibia  was  diseased,  the  other  was  similarly 
affected,  both  as  to  the  position  and  nature  of  the  disease.  In  like  man- 
ner both  fibnlfe  presented  similar  evidences  of  periostitis,  ostitis,  and  exos- 
tosis ;  this  was  true  also  of  the  bones  of  the  foi-earm  (radius  and  ulna)  and 
of  the  clavicle. 

"The  diseased  bones  which  I  collected,"  says  Dr.  Jones,  "from  the 
stone  graves  of  Tennessee  and  Kentucky,  are  probably  the  most  ancient 
sypliilitic  bones  in  the  world."  And  he  adds,  "  this  discovery  appears  to 
be  of  great  importance  in  the  history  of  specific  contagious  diseases,  in 
that  it  confirms  the  view  held  by  some  pathologists  that  syphilis  originated 
in  the  Western  hemisphere." 

It  must  be  confessed  that  the  investigations  of  Dr.  Jones  go  far  to  favor 
the  idea  that  syphilis  existed  among  the  early  aborigines  of  America,  and 
was  conveyed  by  the  crew  and  soldiers  of  Columbus  to  Elurope. 

Again,  according  to  Captain  Dabry,^  Consul  de  France  en  Chine,  Chi- 
nese medical  literature  effords  evidence  of  the  existence  of  syphilis  in  that 
country  and  of  its  treatment  by  mercury,  many  centuries  before  the  birth 
of  Christ. 

In  concluding  this  subject  of  the  origin  of  syphilis,  we  can  only  express 
our  firm  belief  that  this  disease  was  unknown  in  P^urope  prior  to  the  last 
decade  of  the  fifteenth  century,  but  we  may  add,  in  the  words  of  Voltaire, 
"  la  verole  est  comme  les  beaux-arts,  on  ignore  quel  en  a  ete  VinventeurJ'^ 

Age  of  Confusion  in  Venereal The  views  that  were  entertained 

by  those  who  witnessed  the  first  appearance  of  syphilis  in  Europe,  and 
which  in  many  respects  coincided  to  a  remarkable  degree  with  those 
which  luive  been  advanced  in  the  middle  of  the  nineteenth  century,  grad- 
ually lost  tlieir  hold  upon  succeeding  generations,  and  were  followed  by 
th(!  utmost  confusion  of  ideas  respecting  this  subject.  A  most  admirable 
history  of  this  "  age  of  confusion  in  venereal,"  as  it  has  been  called,  is 
given  by  Bassereau,  which  should  be  read  by  every  one  who  would  under- 
stand the  origin  of  those  errors  from  whicli  the  medical  mind  has  cum- 
plet(>ly  freed  itself  only  within  a  very  few  years. 

"A  tendency  on  the  part  of  a  very  few  authors,  as  Vella  (A.  D.  1508), 

'  La  niedec'ine  clu'2  U'S  ohinois,  Paris,  18G3. 


24  INTRODUCTION. 

to  confound  together  the  various  venereal  diseases,  became  manifest  in  the 
early  part  of  the  sixteenth  century,  but  the  absolute  confusion  which  ulti- 
mately reigned,  was  especially  the  work  of  those  physicians,  who  had 
commenced  the  practice  of  their  art  subsequent  to  the  year  1495,  and  who, 
therefore,  were  unable  to  compare  the  new  disease  with  the  venereal 
affections  which  had  prevailed  from  time  immemorial,  before  the  close  of 
the  fifteenth  century.  In  following  the  change  which  took  place,  we  find 
that  the  first  step  was  to  make  no  distinction  in  their  writings  between 
the  old  and  new  ulcer,  and  to  include  in  their  descriptions  of  syphilis  cer- 
tain complications  Avhich  belong  almost  exclusively  to  the  ancient  variety. 
Thus  Nicholas  Massa  (1532),  the  author  of  a  celebrated  treatise  on  the 
French  disease,  includes  among  the  unequivocal  symptoms  of  this  affec- 
tion, suppurating  buboes,  which  accompany  almost  exclusively  the  ulcer 
of  the  ancients. 

"  As  the  venereal  ulcer  of  the  ancients  and  its  attendant  suppurating 
bubo  began  to  be  included  among  the  symptoms  of  syphilis,  treatises  on 
surgery  ceased  to  contain  those  special  chapters  in  which  contagious  ulcers 
of  the  genital  organs  and  inguinal  abscesses  had  heretofore  been  described. 
Discharges  from  the  urethra  were  also  included  among  the  symptoms  of 
syphilis,  and  still  further  modified  the  tableau.  Finally,  in  the  descrip- 
tions given  of  the  French  disease,  not  only  were  symptoms  insei'ted  which 
Avere  completely  foreign  to  syphilis,  but  the  regular  course  of  this  affection 
was  entirely  forgotten. 

"  This  confusion  was  rendered  complete  by  Anthony  Musa  Brassavolus. 
This  physician,  who  was  a  laborious  student  rather  than  a  sagacious  ob- 
server, seems  to  have  made  it  an  object  of  his  treatise  upon  the  '  French 
Disease,'  published  in  1551,  to  collect  together  all  the  errors  of  the  writers 
upon  syphilis  of  this  period,  and  to  add  others  of  his  own  invention.  Not 
only  did  he  include  all  venereal  affections  under  the  head  of  syphilis,  but, 
as  described  by  him,  this  affection  lost  its  characteristic  physiognomy,  and 
was  a  mere  collection  of  symptoms  succeeding  each  other  without  order 
or  regularity.  According  to  this  author,  buboes  may  aj)pear  before  chan- 
cres;  syphilis  may  commence  indifferently  as  an  exostosis,  an  eruption 
u])on  the  skin,  [)ains  in  the  bones,  or  falling  out  of  the  hair  and  teeth. 
He  goes  so  far  as  to  admit  eight  primary  symptoms,  which  he  calls  the 
simple  forms  of  the  disease,  and  which  by  their  union  in  various  ways 
may  give  rise  to  an  infinite  variety  of  combinations,  which  he  terms  the 
com[)ound  forms  of  syphilis,  and  limits  to  two  hundred  and  thirty-four  in 
number. 

"  The  modifications  of  the  doctrines  professed  by  those  who  witnessed 
the  first  appearance  of  syphilis  in  Europe,  could  not  fail  to  affect  the  treat- 
ment of  venereal  diseases.  Before  the  year  1495,  ulcers  of  the  genital 
organs,  the  suppurating  buboes  dependent  upon  them,  the  various  forms  of 
vegetations  and  discharges  fi'om  the  urethra,  were  considered  as  purely 
local  affections,  and  treated  by  means  of  local  remedies.  As  soon  as  the 
French  disease  appeared,  the  insufficiency  of  all  topical  ap|)lications  in  the 
treatment  of  the  new  disease  was  manifest ;  but  human  ingenuity,  never 


HISTORY    OF    VENEREAL    DISEASES.  25 

more  fertile  in  resources  than  under  circumstances  of  great  necessity,  soon 
discovered  in  mercury  a  powerful  modifier  of  the  new  complaint.  For 
several  years  this  remedy  was  employed  in  the  form  of  frictions,  and  only 
in  case  the  patient  had  broken  out  with  an  eruption  following  a  sore  upon 
the  genital  organs ;  but  it  soon  became  the  custom  to  resort  to  mercurial 
inunction  immediately  after  contagion  and  during  the  existence  of  the 
primary  sore,  with  a  view  of  preventing  the  appearance  of  general  symp- 
toms. This  practice  was  lii'st  recommended  by  James  Cataneus,  who 
thought  that  the  same  remedy  which  cured  the  pustular  eruption  would 
also  prevent  it.  '  Hfec  enim  onctio,  absque  dubio,  tale  destruit  virus  quod 
enim  unam  sanat  segritudinem,  ab  eadem  praeservat.' 

"  This  wise  precept,  to  employ  mercurial  medication  during  the  exist- 
ence of  tlie  primary  sore  for  the  purpose  of  preventing  a  general  eruption, 
soon  gave  rise  to  the  most  serious  errors  ;  for,  about  the  time  that  it  was 
given,  physicians  began  to  ignore  the  distinction  between  the  two  species 
of  ulcers,  and  were  consequently  led  to  treat  them  all  indiscriminately 
with  mercury.  This  injurious,  not  to  say  barbarous  practice,  led  to  an 
exaggerated  estimate  of  the  powers  of  mercury,  which,  for  tliree  centu- 
ries, was  given  to  a  multitude  of  patients,  Avho  were  supposed  to  be  pre- 
served through  its  influence  from  symptoms  of  which  they  stood  in  no 
danger. 

"  Hence  Ave  may  explain  the  success  of  all  those  modes  of  treatment 
which  charlatans  have  endeavored  to  substitute  for  mercury  during  the 
existence  of  supposed  primary  symptoms,  as  a  prophylactic  against  sec- 
ondary manifestations  ;  since,  if  the  same  treatment,  no  matter  what,  be 
applied  without  distinction  to  patients  with  gonorrhoea,  ulcerations,  and 
buboes,  there  Avill  always  be  a  large  proportion  who  will  escape  Hirther 
trouble,  for  the  simple  reason  that  their  symptoms  do  not  belong  to  the 
disease  which  first  appeared  in  the  fifteenth  century,  and  are,  therefore, 
incapable  of  infecting  the  general  system." 

The  Modern  School  of  Venereal The  above-mentioned  confu- 
sion of  ideas  relative  to  venereal  diseases,  Avith  the  consequent  indiscrimi- 
nate mode  of  treating  them,  continued  unabated  until  towards  the  close  of 
the  last  century,  and  did  not  wholly  cease  until  after  the  first  half  of  the 
present  century  had  passed.  Even  as  late  as  1850  we  find  Vidal  includ- 
ing under  the  name  of  syphilis  catarrhal  inflammation  of  tlie  genital  oi'- 
gans.  As  late  at  least  as  18G0,  the  Professor  of  Surgery  in  one  of  the 
chief  universities  of  this  country  was  teaching  his  students  that  gonor- 
rha-a  Avas  liable  to  be  followed  by  secondary  symptoms,  and  should  be 
treated  Avith  mercury  ! 

The  identity  of  gonorrhoea  with  syphilis  Avas,  however,  denied  even  in 
the  last  century  by  Astruc,'  Balfour,^  and  Benjamin  Bell.^    It  was  believed 

'  De  morbi  vcnereis,  Paris,  1740. 

2  Dissert,  de  gonorrlupa  virulenta,  Edinburgh,  17l)7. 

3  Treatise  on  gon.  virulentu,  and  lues  venerea,  Edinburgli,  1793. 


26  INTRODUCTION. 

in  by  Hunter,  but  met  with  further  opponents  in  Swediaur/  Hernandez,'^ 
and  especially  Ricord,  who  by  the  use  of  the  speculum  in  venereal  dis- 
eases, and  his  discovery  of  the  chancre  lan-e,  refuted  the  chief  arguments 
which  had  been  adduced  in  its  favor,  and  established  the  non-identity  of 
the  two  diseases  beyond  dispute  forever.  This  was  the  first  step  taken 
towards  the  formation  of  "  The  Modern  School  of  Venereal." 

The  idea  that  all  venereal  sores  are  due  to  a  single  virus,  the  virus  of 
syphilis,  had  been  the  prevailing  one  for  nearly  three  centuries  prior  to 
the  year  1852.  At  the  same  time,  it  had  not  escaped  the  notice  of  many 
observers  that  the  results  of  contagion  were  by  no  means  identical ;  that, 
in  some  cases,  the  persons  infected  showed  no  symptoms  after  the  healing 
of  their  ulcers,  while  others  developed  a  train  of  symptoms  lasting  through 
years,  and  even  transmissible  to  their  children. 

In  the  year  1852,  Bassereau  claimed  a  distinct  cause  or  origin  for  each 
of  these  two  classes  of  cases.  He  founded  his  claim,  first,  on  the  history 
of  venereal  sores,  which  we  have  already  referred  to,  and  which  shows 
that  although  contagious  ulcers  of  the  genital  organs,  communicated  in 
sexual  intercourse,  had  been  well  known  to  the  ancients,  yet  that  the  con- 
stitutional disease  wliich  we  call  syphilis  made  its  first  appeai'ance  in 
Europe  in  the  latter  part  of  the  fifteenth  century. 

Bassereau's  second  argument  was  based  upon  the  "  confi-ontation"  of 
persons  atfected  with  venereal  diseases,  and  he  and  others  were  able  to 
prove,  in  several  hundred  cases,  that  when  tlie  disease  was  local  in  the 
giver  it  was  also  local  in  the  recipient,  and  that  when  it  was  constitutional 
in  the  giver  it  was  always  constitutional  in  the  recipient ;  in  other  words, 
that  the  broad  line  of  distinction  separating  a  local  disease  on  the  one 
hand  from  a  constitutional  disease  on  the  other,  was  constant  in  succes- 
sive generations  without  limit. 

It  will  be  observed  that  this  proof  does  not  involve  any  differences  real 
.  or  supposed  in  venereal  ulcers  themselves  ;  it  may  be  said  to  rise  above 
such  consideration  in  tliat  it  ascends  to  the  source  and  origin  of  such  sores  ; 
and  we  do  not  hesitate  to  say  that  much  of  tlie  confusion  and  contradic- 
tion of  opinion  upon  this  subject  has  been  due  to  the  fact  that  observers 
have  confined  themselves  to  investigating  certain  symptoms  of  venereal 
ulcerations,  which,  though  generally  constant,  may  yet  be  poorly  marked 
or  even  wanting,  and  wliich  often  require  pi-actised  eyes  and  fingers  for 
their  recognition. 

We  maintain  that  this  clinical  proof  adduced  by  Bassereau  has  never 
been  shaken,  for,  althougli  local  ulcers  have  been  produced  by  the  inocu- 
lation of  matter  from  syphilitic  sores,  yet  this  is  susceptible  of,  and  indeed 
requires,  as  we  shall  see  hereafter,  another  explanation  than  an  identity 
of  poisons,  and,  on  the  other  hand,  there  has  never  been  a  single  authentic 
case  in  which  syphilis  has  been  produced  by  the  inoculation  of  cJumcroidal 
matter  from  a  person  tvho  has  had  only  a  chancroid  and  not  syphilis. 

'  Traite  coinplet  dcs  maladies  v6iK'ri(3nnes,  Paris,  1801. 

2  Essai  aiialytique  siir  la  nou-identite  des  virus  goiiorrheique  et  syphilitique, 
Toulon,  1812. ' 


HISTORY    OF    VENEREAL    DISEASES.  27 

Bassereau  does  not  appear  to  have  speculated  on  the  cause  of  the  differ- 
ence in  venereal  ulcers.  We  do  not  find  in  his  work  the  words  "  Unity 
or  Duality  of  Syphilis,"  nor  any  expression  of  opinion  as  to  the  existence 
of  a  specific  virus  for  the  local  sore.  He  simply  says  that  he  is  obliged 
to  recognize  a  difi"erent  cause  {une  cause  differente)  for  the  local  and  con- 
stitutional diseases. 

A  school  of  dualists,  however,  soon  sprang  up,  with  Rollet,  of  Lyons, 
at  its  head,  who  departed  from  the  simple  faith  of  their  founder  in  attach- 
ing undue  importance  to  the  characteristics  of  the  sores  themselves,  and 
who  claimed  for  the  local  sore  a  distinct,  special  virus  of  its  own. 

One  of  the  tenets  of  this  school  was  that  the  secretion  of  syphilitic 
lesions  could  not  be  inoculated  with  success  either  upon  the  person  bearing 
them  or  upon  any  other  person  affected  with  syphilis,  and  this  tenet,  in 
the  theory  of  dualism,  was  looked  upon  as  vital. 

It  was  not  long,  however,  before  it  was  successfully  attacked  and  over- 
thrown. Clerc,  of  Paris,  Melchior  Robert,  of  Marseilles,  and  others, 
succeeded  in  inoculating  the  secretion  of  syphilitic  sores  upon  the  bearers, 
with  the  result  of  producing  ulcers,  without  incubation,  bearing  all  the 
characteristics  of  the  chancroid,  and  inoculable  in  successive  generations. 
Mr.  Henry  Lee,  of  London,  and  Kobner  and  Pick,  in  Germany,  also 
found  that  a  true  chancre  would  become  auto-inoculable,  if  it  was  irritated 
by  the  application  to  its  surface  of  powdered  savine,  or  by  having  a  seton 
passed  through  its  base,  so  as  to  render  its  secretion  decidedly  purulent. 
Again,  Boeck  and  Bidenkap,  in  Christiania,  in  their  later  attempts  at 
syphilization,  took  matter  exclusively  from  true  chancres,  and  obtained  the 
same  result  as  when  they  had  inoculated  chancroidal  pus.  In  five  cases 
reported  by  Bidenkap  and  Gjbr,  of  Christiania,  matter  was  taken  from 
ulcers  obtained  in  the  above  manner,  and  inoculated  by  patients  free  from 
syphilis  upon  tliemselves,  and  in  only  one  instance  did  any  general  symp- 
toms ascribable  to  syphilis  follow,  and  these  were  of  a  doubtful  character. 

These  exjjeriments  apjjarently  proved  the  identity  of  the  syphilitic 
poison  with  that  of  the  local  sore.  By  their  means,  it  was  supposed  that 
the  doctrine  of  duality  was  demolished,  and  the  advocates  of  unity  were 
triumphant.  Wliether  this  conclusion  was  not  too  hasty,  we  shall  presently 
take  occasion  to  inquire.  But  these  experiments  actually  did  prove  the 
absence  of  any  distinct  specific  virus  in  the  chancroid,  incapable  of  genera- 
tion de  novo;  for  here  were  chancroids  artificially  produced  independently 
of  any  descent  from  chancroids. 

To  defend  tliemselves,  the  dualistic  school  took  refuge  in  the  "mixed 
chancre,"  a  sore  combining  both  the  sy[)hilitic  and  chancroidal  poisons, 
whicli,  it  was  asserted,  would  satisfiictorily  explain  all  these  cases  and  still 
leave  the  tenets  of  dualism,  as  at  that  time  understood,  intact.  This  ex- 
})lanafion  was  for  a  wliile  regarded  as  satisfactory,  but  it  could  no  longer 
be  upheld  when  such  experiments  had  been  multi[)lied  indefinitely;  when 
their  number  was  so  great  that  the  chance  of  the  commingling  of  two 
kinds  of  specific  virus  and  their  simultaneous  inoculation  was  reduced  to 
an  absurdity;  when  an  indurated  syphilitic  primary  lesion  could  be  taken 


28  INTRODUCTION. 

at  random,  and,  after  due  irritation,  its  secretion  could  be  successfully 
inoculated  with  the  effect  of  producing  pustules  and  ulcers  bearing  every 
characteristic  of  the  chancroid;  and  when  the  same  result  could  even  be 
obtained  at  will  by  the  inoculation  of  the  secretion  from  a  purely  secondary 
lesion,  as,  for  instance,  a  syphilitic  mucous  patch !  If  the  chancroid  was 
dependent  upon  a  distinct  specific  virus,  its  presence  in  all  these  cases  was 
simply  impossible,  and  yet  not  a  single  shade  of  difference  could  be  pointed 
out  between  the  result  produced  and  tliat  from  the  most  emblematic  clian- 
croid  ever  met  with  in  practice.  Dualism  was  indeed  henceforth  dead,  if 
by  "dualism"  be  meant  that  each  of  the  two  kinds  of  venereal  sore  has  a 
distinct,  specific  virus  of  its  own.  In  the  face  of  the  experiments  referred 
to,  we  cannot  believe  it  possible  to  defend  in  future  any  such  doctrine  of 
duality. 

But  the  last  word  bad  not  been  spoken  in  fixvor  of  a  distinct  origin  of 
the  chancroid  from  that  of  syphilis,  nor  the  last  experiment  made  and 
recorded  wliich  would  decide  this  question.  Let -us  examine  moi'e  care- 
fully the  experiments  just  referred  to.  What  was  the  matter  so  successfully 
inoculated?  The  pure,  unmixed  virus  of  syphilis?  By  no  means.  It  was 
a  compound  product,  taken,  to  be  sure,  from  a  syphilitic  lesion,  but  a  lesion 
irritated  commonly  to  suppuration  by  artificial  means;  containing  possibly 
the  germ  of  syphilis,  but  containing  also,  and  in  fact  chiefly  composed  of, 
pus.  Whicli  of  these  two  fjictors  was  responsible  for  the  effect  produced? 
The  syphilitic  virus?  In  that  case  this  virus  should  have  preserved  its 
power  of  infecting  the  constitution,  and  matter  taken  from  these  ulcers, 
and  inoculated  upon  healthy  individuals,  should  invariably  have  produced 
syphilis,  which  has  been  shown  not  to  be  true.  IMoreover,  if  it  could  be 
proved  tliat  pus  alone,  free  from  all  suspicion  of  sy[)hilitic  mixture,  was 
capable  of  producing  the  same  result,  then  p)is  was  the  guilty  factoi',  and 
tliere  Avas  no  such  transformation  as  supj)osed  by  the  unitists.  Such  i)roof 
we  now  have,  as  will  be  seen  from  the  following  cases: — 

In  18G5,  Prof.  Pick,  at  the  suggestion  of  Prof.  Zeissl,  inoculated  sim- 
ple, non-venereal  matter  of  inflammatory  origin  upon  syphilitic  subjects. 
Taking  the  secretion  of  pemphigus,  acne,  scabies,  and  lupus,  he  inocu- 
lated it  upon  persons  affected  with  sy[)liilis  and  produced  pustules,  not 
preceded  by  incubation,  and  the  matter  of  which  was  further  inoculable 
through  several  generations.  Counter-inoculations  upon  the  persons  free 
from  syphilis  who  were  the  bearers  of  these  affections,  were  without  effect. 
Tlie  same  result  was  attained  by  Kraus  and  Reder  with  the  pus  of  scabies, 
and  by  Henry  Lee  witli  pus  from  a  non-syj)hilitic  child.  The  late  Mr. 
Morgan,  of  Dublin,  also  succeeded  in  producing  pustides  and  ulcers,  iden- 
tical in  ap[)earance  with  the  chancroid  and  capable  of  re-inoculation  tlirough 
a  number  of  generations,  by  inoculating  syphilitic  women  witli  their  vaginal 
secretions. 

It  would  thus  appear  tliat  the  skin  of  sy[)hilitic  individuals  possesses  a 
marked  vulnerability,  a  peculiar  aptitude  to  become  inflamed  when  acted 
u[)on  by  irritants  ;  but  this  is  nothing  more  than  is  seen  in  other  and  in 
non-syphilitic  subjects,  wdiose  vital  j)0wers  are   impaired  by  any  cause 


HISTORY    OF    VENEREAL    DISEASES.  29 

wliatever.  For  instance,  it  is  well  known  that  amonn;  medical  students 
engaged  in  the  dissecting-room,  it  is  those  who  are  run  down  by  hard 
study  and  overwork,  who  are  most  likely  to  become  inoculated  by  fluids 
from  the  dead  body.  Again,  the  idea  which  was  entertained  by  some 
that  there  must  be  a  syphilitic  soil  for  such  inoculations  to  succeed  upon, 
has  since  been  disproved  by  other  experiments. 

The  earliest  of  these  experiments,  so  far  as  I  am  aware,  have  never 
been  published,  and  were  performed  in  the  winter  of  1867-8  by  Dr.  Ed- 
ward Wigglesworth,  Jr.,  of  Boston,  upon  himself,  while  pursuing  his 
studies  at  Vienna.  He  has  kindly  furnished  me  witii  the  following  his- 
tory: After  stating  the  grounds  which  led  him  to  the  conclusion — origi- 
nal, it  appears,  with  himself — that  '■'■  jnis  pure  and  simple  might  be  the 
cause  of  the  chancroid,^'  Dr.  W.  says  : — 

"  I  would  state  that  I  was  free  from  all  disease  either  hereditary  or  ac- 
quired ;  that  I  had  never  had  a  sore  of  any  kind  or  any  local  or  constitutional 
lesion  of  the  skin  or  mucous  membranes,  and  that  I  was  merely  a  little  run 
down  from  overwork  in  the  hospital.  I  took  from  an  acne  pustule  upon 
myself,  pus,  which  I  inoculated  upon  myself  in  three  places  on  the  anterior 
radial  aspect  of  my  left  forearm  at  the  junction  of  the  middle  and  upper 
thirds,  first  pricking  open  the  apertures  of  hair  follicles  and  then  rubbing 
the  pus  into  them.  The  result  in  the  course  of  three  or  four  days  was 
three  well-marked  pustules.  From  each  of  these  I  inoculated  one  new 
spot  upon  the  same  arm  nearer  the  wrist.  The  result  was  three  ncAV  well- 
marked  pustules.  From  each  of  the  three  second  series  I  again  inoculated 
fresh  spots  still  nearer  the  wrist,  and  again  the  result  was  positive.  The 
second  series  was  hardly  as  well  marked  as  the  first,  and  the  third  series 
was  slightly  inferior  in  vigor  to  the  second  ;  still  all  were  well  marked,  the 
nine  sores  being  at  the  same  time  present  upon  my  arm.  On  removal  of 
the  crusts,  perceptible  ulceration  of  the  skin  was  found  to  exist.  Zeissl, 
with  whom  I  was  studying  at  the  time  (18G7-8),  happened  to  be  lecturing 
upon  dualism,  and  requested  me  to  show  my  arm  to  the  class  to  prove  the 
production  of  ulceration  from  properly  inoculated,  simple,  healthy  pus. 
There  were  no  buboes  in  my  case,  nor  did  the  ulcerations  require  other 
treatment  than  exclusion  from  the  air  by  means  of  a  simple  dressing,  and 
cleanliness.  The  scars  remain  to  the  present  day.  I  tluis  convinced  my- 
self and  others — 

"  I.  That  the  products  of  inflammatory  action,  if  properly  introduced 
into  the  human  integument,  may  cause  local  ulcers,  closely  resembling 
chancroids  and  re-inoculable  in  generations. 

"  II.  That  this  pus  need  not  come  from  a  syphilitic  person  or  be  inocu- 
lated upon  a  syi)hilitic  person.  If  taken  from,  or  inoculated  upon,  a  per- 
soji  debilitated  by  any  disease  as  syphilis,  the  efiect  woidd  doubtless  Ije  the 
same  though  probably  greater  in  intensity." 

Many  years  sul)se(iuent  to  these  experiments  of  Dr.  Wigglesworth, 
Kaposi'  published  the  following  statement :    "  ]\Iy  own  experiments  have 

'  Die  Syphilis  der  Haul,  etc.,  p.  47. 


30  INTRODUCTION. 

taught  me  that  non-specific  pus,  sucli  as  that  from  acne  and  scabies-pustules, 
when  inoculated  upon  tlie  bearers  as  well  as  upon  otlier  non-syphilitic 
persons,  will  produce  pustules  whose  pus  proves  to  be  continuously  inocu- 
lable  in  generations  ;  that  from  these  pustules  losses  of  substance  occur, 
which  heal  with  the  formation  of  scar-tissue ;  and  that  as  the  number  of 
pustules  produced  increases,  the  inoculability  of  the  pus  derived  from  them 
diminishes  and  finally  ceases  altogether." 

It  is  not  necessary  to  dwell  upon  the  exact  correspondence  of  the  result 
of  such  inoculations  and  that  obtained  by  tlie  inoculation  of  the  so-called 
chancroidal  virus. 

The  following  case,  occurring  in  the  practice  of  Dr.  R.  "W.  Taylor  and 
vouched  for  by  him  in  all  its  details,  is  an  instance  of  a  chancroid  origina- 
ting de  novo. 

"  C.  P.  C,  aged  26,  became  syphilitic  in  1869,  presenting  primary  and 
secondary  lesions.  In  March,  1870,  he  had  a  papular  syphilide  on  the 
body,  and  on  the  10th  of  that  month  he  came  to  me  with  gonorrhoea  in  its 
acute  stage.  On  the  sixteenth  he  came  with  an  inflamed  group  of  unrup- 
tured herpetic  vesicles,  in  every  respect  typical.  He  feared  these  Avere 
chancres,  but  said  he  had  not  had  connection  since  the  first  of  the  month. 
At  this  time  the  gonorrhoea  was  still  active.  On  the  twenty-second  he 
returned,  feeling  certain  that  he  had  chancres.  I  then  found  four  typical 
oval  cliancroids  on  the  under  portion  of  the  prepuce  over  which  the  gonor- 
rhoeal  pus  had  flowed,  since  he  had  failed  to  follow  my  advice  to  keep  the 
vesicles  properly  protected.  His  gonorrhoea  was  then  on  the  decline.  On 
the  twenty-sixth  lie  complained  of  pain  in  the  right  groin,  and  I  found 
several  enlarged  painful  glands.  In  spite  of  thorough  cauterization  at  the 
jirevious  consultation,  the  chancroids  were  still  active.  A  few  days  later 
while  intoxicated,  he  had  intercourse  witli  his  wife,  and  about  March  31st 
he  told  me  he  feared  that  she  had  become  infected.  On  the  5th  of  April, 
the  wife  came  to  me  with  five  or  six  typical  chancroids  at  the  fourcliette 
and  on  the  inner  aspect  of  the  labia  minora.  At  this  time  the  husband's 
chancroids  were  in  process  of  repair,  but  he  liad  a  typical  cliancroidal  bubo. 
Owing  to  neglect  on  the  part  of  the  wife  her  ulcers  became  very  extensive 
and  were  followed  by  abscess  in  the  groin,  neither  of  which  healed  for 
more  than  a  month.  U[)  to  this  time  I  have  reason  to  believe  that  the 
wife  had  led  an  irreproachable  life.  She  certainly  liad  never  had  syphilis. 
But,  learning  of  her  husband's  infidelity,  she  became  reckless,  and  two 
years  afterwards  contracted  from  another  man  a  hard  chancre  on  the 
left  labium  majus,  for  which,  as  well  as  for  the  subsequent  secondary  symp- 
toms, she  was  treated  by  myself. 

"  To  review  the  case  briefly,  a  syphilitic  man  contracts  a  gonorrha'a  and 
subsequently  develops  herpes  vesicles,  which  in  a  few  days  are  converted 
into  typical  chancroidal  ulcers.  I  inoculated  some  of  the  discharge  from 
the  ulcers  upon  the  patient's  abdomen,  and  within  a  week  a  characteristic 
chancroid  was  developed.  The  experiment  was,  however,  unnecessary, 
since  additional  proof  was  furnislied  by  the  formation  of  several  chancroids 
on  his  left   thigh,  in   consequence  of  liis   careless  and   uncleanly  habits. 


HISTORY    OF    VENEREAL    DISEASES.  31 

Finally,  intercourse  with  his  wife  resulted  in  her  having  chancroids  and 
buboes." 

The  idea  that  the  products  of  inflammation  are  the  source  from  which 
the  chancroid  springs,  and  that  the  simultaneous  inoculation  of  these  pro- 
ducts and  of  the  germs  of  syphilis  accounts  for  the  varying  degrees  of 
ulceration  and  other  phenomena  met  with  in  varieties  of  venereal  sores, 
will  strike  many  as  novel,  and  it  is  easy  to  foresee  the  objections  which 
will  naturally  arise.  It  will  be  asked :  Can  it  be  possible  that  the  pus 
from  acne,  ectliyma,  or  scabies  can  give  rise  to  a  sore  equal  in  duration 
and  severity  to  that  produced  by  matter  from  a  typical  chancroid  ?  Com- 
parative inoculations  upon  the  same  individual  with  these  two  agents  may 
even  be  adduced  to  show  that  this  is  not  the  case.  In  replying  to  such 
objections,  it  must  be  frankly  admitted  that  Ave  do  not  as  yet  fully  under- 
stand all  the  laws  governing  the  inoculation  of  septic  matter.  We  cannot, 
for  instance,  fully  explain  why  one  individual  should  be  more  susceptible 
than  another,  why  ditferent  parts  of  the  integument,  as  that  of  the  chest, 
the  arms,  and  the  thighs,  should  develop  ulcers  so  varying  in  their  destruc- 
tive tendency  as  is  shown  in  the  practice  of  syphilization  ;  why  the  secre- 
tion from  purulent  urethritis  and  purulent  conjunctivitis  should  be  inter- 
changeable, and  yet  have  no  effect  upon  the  mucous  membranes  of  the 
mouth,  nose,  or  ear ;  why  a  chancroid  of  the  prepuce  should  inoculate 
other  points  of  that  membrane,  and  yet  commonly  spare  the  glans  penis ; 
or  why  one  upon  the  os  uteri  should  allow  the  walls  of  the  vagina  in  con- 
tact with  it  to  escape  ;  and  so  with  other  instances  that  might  be  brought 
forward. 

That  the  effect  produced  is  to  a  great  extent  proportionate  to  the  ulcer- 
ative action  of  the  source  from  which  the  matter  is  taken,  is  evident  to 
any  one  who  has  performed  auto-inoculation  from  indurated  chancres.  If 
the  chancre  consist  of  a  simple  erosion  with  a  watery  secretion,  seated 
upon  an  indurated  base,  the  first  two  or  three,  or  even  more,  attempts  at 
auto-inoculation  will  probably  fail;  but  as  the  surface  of  the  sore  becomes 
irritated  to  suppuration  by  repeated  pricks  of  the  lancet,  these  attempts 
will  succeed,  first  in  producing  minute  pustules  and  ulcers,  but  subse- 
quently, as  the  suppuration  increases,  others  larger  and  better  developed. 
Taking  these  facts  into  consideration,  it  need  not  be  wondered  at  if  com- 
parative inoculations  upon  tlie  same  individual  with  matter  from  a  simple 
skin  affection  and  from  a  chancroid  of  the  genitals,  should  show  greater 
severity  in  the  latter.  But  without  entering  further  into  this  subject,  we 
claim  it  to  be  sufficient  to  have  shown  that  the  inoculation  of  the  products 
of  inflammation  will  produce  an  effect  identical  in  kind,  even  if  not  in 
degree,  with  that  of  matter  from  tlie  most  typical  chancroid. 

The  conclusions  at  which  we  have  arrived  may  be  summed  up  as  fol- 
lows:— 

I.  7'he  chancroid  is  entirely  distinct  from  syphilis. 

II.  The  chancroid,  however,  does  not  depend  vpon  a  specific  virus  of 
its  oivn,  incapable  of  being  generated  de  novo. 

III.  The  chancroid,  in  most  cases  met  with  in  practice,  is  derived  from 


32  INTRODUCTION. 

a  chancroid,  hut  it  may  arise,  especially  in  perso7is  debilitated  by  any 
cause,  from  inoculation  of  tJie  products  of  inflammation,  either  simple  or 
syphilitic,  and  subsequently  perpetuate  itself  from  one  individual,  to  an- 
other as  a  chancroid. 

lY.  I'he  simultaneous  inoculation  of  the  syphilitic  virus  and  of  the 
products  of  inflammation  gives  rise  to  the  '•^  mixed  chancre,^''  and  explains 
the  different  degrees  of  ulceration  which  the  initial  lesion  of  syphilis  is 
liable  to  assume. 

We  hold  that  this  view  of  the  nature  of  the  chancroid  is  most  consistent 
with  our  present  knowledge  of  pathology,  and  that  it  affords  the  only 
complete  and  satisfactory  explanation  of  certain  cases  met  with  in  practice 
and  of  the  phenomena  observ'ed  in  artificial  inoculations.  It  has  been 
adopted  by  Biiumler,  who,  in  his  recent  able  work  on  syphilis,  after 
quoting  experimental  inoculations  like  those  above  given,  says:  "The 
necessary  conclusion  is,  that  the  poison  of  the  soft  chancre  may,  under  cer- 
tain circumstances,  he  produced  de  novo  without  the  intervention  of  the 
syphilitic  virus,  Avhile  the  syphilitic  poison  propagates  itself  only  in  one 
continuous  series.  Hence  the  chancroidal  poison,  or  whatever  in  these 
experiments  produced  the  pustules  resembling  chancroids,  cannot  even  be 
compared  with  the  syphilitic  poison,  to  say  nothing  of  regarding  them  as 
identical." 

In  the  recent  well-known  debate  upon  syphilis  before  the  Pathological 
Society  of  London,  that  accomplished  surgeon,  Mr.  Hutchinson,  came 
within  one  short  step  of  the  truth  when  he  admitted  the  origin  of  the  local 
venereal  sore  to  be  "the  products  of  syphilitic  inflammation,  but  not  usually 
containing  the  germs  of  syphilis."  If  he  had  omitted  the  adjective, 
"syphilitic,"  before  the  word  "inflammation,"  his  expression  would  have 
been  consistent  with  the  facts  at  present  in  our  possession,  and  he  would 
have  found  it  inconsistent  with  such  facts  to  proclaim  dualism  as  dead, 
since  dualism  is  nothing  more  tlian  a  duality  of  poisons  in  the  evolution  of 
venereal  sores. 

If  the  view  here  advocated  be  the  correct  one,  it  suggests  an  interesting 
analogy  with  the  history  of  our  belief  as  regards  the  nature  of  gonorrhoea, 
an  afliection  which  in  the  last  century  was  regarded  as  due  to  the  sy[)hilitic 
virus.  IJicord  finally  adduced  convincing  proof  that  it  had  nothing  to  do 
witli  syphilis.  It  was  afterwards  supposed  to  depend  upon  a  virus  of  its 
own,  the  gonorrheal  virus.  We  now  know  that  it  may  be  caused  by  any 
simple  irritant,  but  more  especially  by  the  pus  from  the  urethral  and  other 
inflamed  mucous  membranes,  whether  originating  or  not  in  contagion. 
Such  as  the  history  of  gonorrlujea  has  been,  so,  we  predict,  the  history  of 
the  chancroid  will  be. 

In  the  preceding  remarks,  we  have  only  casually  alluded  to  the  evidence 
in  favor  of  a  duality  of  poisons  to  be  found  in  the  symptoms  presented  by 
venereal  sores  themselves,  and  by  the  lymphatic  ganglia  in  anatomical 
relation  witli  them.  The  value  of  this  evidence  must  always  depend  upon 
the  observer's  knowledge,  skill,  and  experience  in  venereal  diseases.  How 
often  do  we  witness  the  grossest  errors  in  the  diagnosis  of  venereal  ulcers 


DIVISION    OF    THE    PRESENT    WORK.  33 

made  by  men  who  are  deservedly  eminent  in  general  practice!  Moreovei", 
instances  not  unfrequently  occur  in  which  the  svmptoms  are  ill-defined, 
and  in  which  the  most  experienced  will  wait  for  further  developments 
before  expressing  an  opinion.  Hence,  so  long  as  the  symptoms  of  the 
sores  themselves  were  alone  considered,  the  question  of  unity  or  duality 
remained  undecided.  And  yet  the  evidence  founded  on  these  symptoms 
is  not  to  be  despised,  for  in  the  great  majority  of  cases  they  are  sufficient 
to  enable  us  to  distinguish  the  syphilitic  from  the  local  sore,  and  the 
obscurity  of  some  cases  is  readily  explicable  on  the  ground  of  the  simulta- 
neous inoculation  of  the  products  of  inflammation  and  the  germs  of  sy[)hilis, 
and  the  well-known  immediate  action  of  the  one  and  the  incubation  of  the 
other. 

DiA'ISION   OF   THE   PRESENT   WORK. 

Following  the  natural  order  suggested  by  the  above  considerations,  we 
propose  to  divide  the  present  work  into  three  parts  :  the  First  treating  of 
Gonorrhoea  and  its  Complications  ;  the  Second  of  the  Local  Contagious 
Ulcer  of  the  Genitals,  or  Chancroid,  and  its  Complications;  and  the  Third 
of  Syphilis. 


PART  I. 
GONOERIKEA  AND  ITS  COMPLICATIONS. 


CHAPTER    I. 
URETHRAL   G  O  X  O  R  R  H  03  A   IN   THE   ]M  A L E  , 

Preliminary   Considerations By  far  the  most  frequent  disease 

originating  in  sexual  intercourse,  is  an  affection  of  certain  mucous  mem- 
branes, a  prominent  symptom  of  which  is  an  increased  secretion  and  dis- 
charge from  the  diseased  surface.  At  various  times  and  places,  this 
disease  has  received  different  names  founded  on  the  prevailing  ideas  of  the 
nature  of  the  secretion  referred  to.  At  an  early  period  in  the  history  of 
Venereal,  the  discharge  was  supposed  to  consist  of  the  semen,  and  hence 
the  disease  was  called  gonoiTlicjea,  from  yovri,  sperm,  and  jjf«,  to  flow;  a 
name  whicli  is  still  in  use  among  American  and  English  writers  notwith- 
standing the  incorrectness  of  the  supposition  in  which  it  originated.^  The 
French  call  the  same  affection  "blenorrhagie,"  or  a  flow  of  mucus,  a  name 
which  is  also  erroneous,  since  the  discharge  does  not  consist  of  mucus 
alone,  but  of  a  mixture  of  mucus  and  pus.  In  popular  language  it  is 
termed  "cla[)"*  by  the  English,  and  "•chaude-pisse"  by  the  French. 

The  chief  mucous  membranes  subject  to  gonorrhoea  are  those  lining  the 
genital  organs  in  the  two  sexes,  and  tlie  conjimctiva  oculi.  Gonorrhoea 
of  the  anus,  mouth,  and  nose  are,  indeed,  mentioned  by  authors,  but  tlie 
existence  of  all  of  tliem  is  more  or  less  doubtful. 

The  symptoms  and  tlie  treatment  of  gonorrluea  vary  according  as  the 
disease  att'ects  the  male  or  female,  and  according  also  to  the  portion  of 
mucous  membrane  attacked  ;  it  will  be  convenient,  therefore,  to  consider 
this  affection  under  corresponding  lieads. 

'  Cockburne  (Tlio  Syiuptoins,  Nature,  Cause,  and  Cure  of  Gonorrhoea,  London, 
T757)  first  established  the  fact  that  goiiorrhcjua  is  not  a  How  of  semen. 
2  Clip,  clap,  dippe,  to  embrace;,  to  fontUe. 

"  CliX'pe  wc  in  covenant,  and  nach  of  iis  clip/>e other.'" — Piers  Pluiif/hiiinn. 
"  He  kisselh  her  and  clippe.th  her  lull  oft." — Chaucrr  ;    Tim  Merclmnt's  Tale. 
"  Oh,  let  me  clip  ye  in  arms  as  round  as  when  I  woo'd  1'" — Shakspeare:  Coriolanus. 
"  The  lusty  vine,  not  jealous  of  the  ivy. 

Because  she  flips  the  elm '."' — Beaumont  and  Fletcher. 

"Old  French,  c/a/)/'ses,  public  shops  kept  by  prostitutes.  Iloblijn; — claj>iers,  au 
old  term  fur  houses  of  ill  fame." 


36  urethral  gonorrhoea  in  the  male. 

Urethral  Gonoukikea  in  the  Mai.k. 

Men  are  more  liable  to  conti-act  gonorrlioea  than  women  ;  and  of  a  given 
number  of  cases  of  this  disease  in  the  former,  in  a  large  proportion  it  is 
the  urethra  which  is  affected.  Cases  of  urethral  discharge  in  the  male 
outnumber  all  other  forms  of  gonorrhoea  in  the  two  sexes  combined.  The 
explanation  of  this  fjict  will  appear  when  we  come  to  consider  the  causes 
and  nature  of  gonorrhoea. 

Symptoms. — The  symptoms  of  urethral  gonorrhoea  in  the  male  first 
appear,  as  a  general  rule,  between  the  second  and  fifth  day  after  exposure; 
though,  in  exceptional  cases,  as  late  as  the  seventh,  tenth,  or  fourteenth 
day;  but  their  occurrence  after  this  time,  as  alleged  by  some  authors,  is, 
I  believe,  to  be  explained  on  the  ground  that  the  earliest  manifestations  of 
the  disease  have  been  overlooked.  At  first,  the  symptoms  are  very  slight, 
consisting  only  of  an  uneasy  and  tickling  sensation  at  the  mouth  of  the 
canal,  which,  on  examination,  is  found  more  florid  than  natural,  and  moist- 
ened with  a  small  quantity  of  colorless  and  viscid  fluid,  which  glues  the 
lips  of  the  meatus  together.  This  moisture  of  the  canal  gradually  increases 
in  amount,  until  on  pressure  a  drop  may  be  made  to  appear  at  the  orifice  ; 
at  the  same  time  it  begins  to  lose  its  clear  watery  appearance,  and  assumes 
a  milky  hue.  Examined  under  the  microscope,  it  is  found  to  consist  of 
mucus  with  the  addition  of  pus-globules;  the  number  of  the  latter  being 
proportioned  to  the  depth  of  color  of  the  discharge.  '  Meanwhile,  some 
smarting  is  felt  by  the  patient  in  the  anterior  portion  of  the  canal  during 
the  passage  of  the  urine. 

Such  are  the  symptoms  of  the  early  stage  of  gonorrha-a.  The  exciting 
cause  of  the  disease  has  been  applied  to  that  portion  of  the  canal  w^hich 
lies  near  the  orifice  of  the  meatus  and  wliicli  was  chiefly  exposed  to  conta- 
gion, and  the  ensuing  inflammation  is  gradually  lighted  up  in  this  part, 
and  has  not  yet  extended  beyond  that  portion  of  the  urethra  known  as  the 
fossa  navicularis.  This  early  stage  of  gonorrhoea  is  often  called  "  the  stage 
of  incubation,"  a  name  which  is  objectionable  because  the  inflammatory 
process  is  doubtless  set  up  at  the  time  of  the  application  of  the  exciting 
cause.  Time  is  required  for  it  to  produce  its  full  effect,  and  the  earliest 
symi)toms  are  but  slowly  and  gradually  ushered  in.  A  more  ai)propriate 
name  is  tlie  first  or  preparatory  stage. 

The  flrst  stage  of  gonorrhoea  usually  lasts  from  two  to  four  days.  The 
symptoms  gradually  increase  in  intensity,  until,  in  about  a  week  after  ex- 
posure, the  second  or  inflammatory  stage  may  be  said  to  commence.  If 
we  examine  the  penis  during  this  stage,  we  And  the  mucous  membrane 
covering  the  glans  reddened,  and  the  whole  extremity  of  tlie  organ  swol- 
len so  that  the  pre])uce  fits  more  tightly  than  natural.  In  some  cases  the 
latter  is  pufled  out  by  ojdema  in  the  cellular  tissue,  and  phimosis  may 
exist,  rendering  it  imi)0ssible  to  uncover  the  glans.  'I'lie  inflammatory 
blush  is  especially  marked  in  the  neighborhood  of  the  meatus,  the  lips  of 
which  are  swollen  so  as  to  contract  the  calibre  of  the  orifice.     The  urethra 


SYMPTOMS.  37 

is  slightly  more  prominent  tlian  natural  along  the  under  surface  of  the 
penis,  and  is  sensitive  on  pressui-e  especially  in  the  neighborhood  of  the 
fossa  navicularis.  The  discharge  has  now  become  copious,  so  much  so  in 
some  instances  as  to  drop  from  the  meatus  as  the  patient  stands  before 
you.  It  is  thick,  of  a  yellowish  cream  color,  and  not  unfrequently  tinged 
with  green.  This  greenish  hue,  as  in  the  sputa  of  pneumonia,  is  due  to 
the  admixture  of  blood-corpuscles,  which  may  be  sufficiently  numerous  to 
produce  the  characteristic  color  of  blood.  The  penis  generally,  and  espe- 
cially upon  the  under  surface  over  the  course  of  the  canal,  is  painful  and 
tender  on  pressure. 

While  passing  his  urine,  the  patient  complains  of  intense  pain  which  is 
now  not  confined  to  the  anterior  part  of  the  canal,  but  is  felt  in  all  that 
])ortion  of  the  organ  anterior  to  the  scrotum,  or  is  even  more  deeply  seated. 
The  severity  of  the  suffering  during  the  act  is  in  some  instances  very  great. 
The  pain  is  compared  to  the  sensation  of  a  hot  iron  introduced  within  the 
canal ;  and  the  popular  name,  cliaude-pisse,  given  to  the  disease  by  the 
French,  is  fully  justified.  This  pain  is  excited  in  part  by  the  irritation 
produced  upon  an  abnormally  sensitive  membrane  by  the  salts  contained 
in  the  urine,  but  chiefly,  I  am  inclined  to  think,  by  the  distention  of  the 
contracted  and  sensitive  canal  by  the  passage  of  the  stream.  Hence, 
during  the  act,  tlie  patient  involuntarily  relaxes  the  abdominal  walls,  holds 
his  breath,  and  keeps  the  diaphragm  elevated,  in  order  to  diminish  the 
pressure  upon  the  bladder  and  lessen  the  size  and  force  of  the  stream  of 
urine.  In  consequence  also  of  the  urethra  being  contracted  and  more 
or  less  obstructed  by  the  discharge,  the  stream  is  forked  or  otherwise 
irregular. 

Chordee — Another  source  of  suffering  in  this  stage  of  gonorrhoea  is  the 
nocturnal  erections,  which  are  apt  to  come  on  after  the  patient  is  warm  in 
bed.  The  genital  organs  are  in  a  highly  sensitive  condition,  and  are 
I'eadily  excited  by  lascivious  dreams,  the  contact  of  the  bedclothes,  or  a 
distended  bladder  ;  or,  independently  of  such  exciting  cause,  they  assume 
a  state  of  erection  which  even  in  health  is  more  apt  to  occur  during  sleep. 
"When  thus  excited,  it  will  often  be  found  that  the  penis  is  bent  in  the 
form  of  an  arc  with  its  concavity  downward.  Tliis  condition  is  known  as 
chordee.  Its  explanation  is  very  simple.  The  urethra,  the  chief  seat  of 
the  inflammation,  runs  along  the  under  surfiice  of  the  penis.  Plastic 
lymph  is  effused  around  the  canal,  gluing  the  tissues  together  and  render- 
ing this  portion  of  the  penis  less  extensible  than  the  remaining  portion 
composed  of  the  corpora  cavernosa.  Hence,  in  a  state  of  erection,  the 
corpus  spongiosum  surrounding  the  urethra,  not  being  able  to  yield  to  the 
, extension,  acts  like  the  string  of  a  bow,  and  chordee  is  produced.  The 
stretching  of  tiie  parts  thus  adhering  together  excitfjs  pain,  which  is  often 
very  severe.  The  sufferer,  awaking  from  sleep,  instinctively  grasps  the 
penis  in  his  hand,  and  bends  it  into  a  still  smaller  curve,  so  as  to  remove 
tlie  strain  from  the  under  surface  and  thus  ease  the  pain.  I  have  been  in 
the  habit  in  my  lectures  of  illustrating  the  mechanism  of  chordee  by  gluing 


38  URETnRAL    GONORRHtEA    IN    THE    MALE. 

a  piece  of  tape  along  the  surface  of  an  India-rubber  condom,  and  then  dis- 
tending it  with  air  or  water. 

The  above  ex|)lanation  of  the  meclianism  of  chordee  is  tlie  one  usually 
received,  though  it  is  proper  to  state  that  it  is  rejected  by  Mr.  Milton,  who 
believes  that  chordee  is  due  to  spasm  of  the  muscular  fibres,  which  Kolliker 
and  Mr.  Hancock  have  shown  to  exist  around  the  whole  course  of  the 
urethra.  Milton's  explanation  is  opposed  by  the  fact  that  bending  the 
})enis  so  as  to  increase  the  curve  of  the  arc  affords  partial  ease  to  the  pain 
of  chordee  ;  and  I  am  not  convinced  that  the  generally  received  opinion 
should  thus  be  laid  aside,  though  it  is  highly  probable  that  spasmodic  mus- 
cular action  plays  some  part  in  the  production  of  the  frequent  erections 
and  chordee  which  take  place  in  gonorrhrea. 

Hemorrhage In    the   congested  state   of  the  vessels  of   the  urethral 

mucous  membrane  which  obtains  in  acute  gonorrhoea,  it  is  not  surprising 
that  blood  should  sometimes  be  found  mixed  with  the  discharge,  imparting 
to  it  a  reddish  or  rusty  hue.  This  is  the  ordinary  extent  of  the  hemor- 
rhage, although  it  may  amount  in  a  few  rare  cases  to  a  decided  flow  of 
arterial  blood,  even  when  no  special  reason  for  its  appearance,  other  than 
the  gonorrhea,  is  known. 

It  is,  however,  under  sexual  excitement  that  the  hemorrhage  is  most 
likely  to  be  free,  and  even  alarming,  especially  to  the  patient  and  his 
friends.  The  occasion  of  it  may  be  simply  a  violent  erection.  More  com- 
monly it  is  prolonged  sexual  excitement,  induced  by  the  presence,  even  in 
the  absence  of  fondling,  of  the  fair  individual  to  whom  the  trouble  was 
originally  due.  Any  excess  in  exercise — walking,  standing,  etc.,  or  any 
attempt  at  coitus  which  may  be  made  if  a  man  is  under  the  effects  of 
li(juor,  will  evidently  favor  the  same.  Again,  there  is  a  practice  in  vogue 
among  men  of  the  town  abroad,  much  more  than  in  this  country,  of 
"  breaking  the  cord,"  which  consists  in  relieving  themselves  of  the  pain  of 
cliordee  by  laying  the  erected  and  bent  penis  upon  a  flat  surface  and 
straightening  it  by  a  blow.  This  dangerous  practice  is  often  followed  by 
a  copious  hemorrhage,  which  may  subsequently  return  on  slight  excite- 
ment, the  vessels  having  once  been  ruptured.  I  say  "  dangerous,"  chiefly 
on  account  of  the  liability  to  hemorrhage  following.  It  is  said  that  it  may 
also  produce  stricture,  which  is  not  uidikely.  At  any  rate  the  practice  is 
barbarous. 

The  amount  of  blood  lost,  under  either  of  the  aljove  circumstances, 
varies  of  course  in  different  cases.  "  A  little  blood  goes  a  long  way,"  so 
that  the  statements  of  patients  should  be  received  cum  grano  salt's;  but 
competent  observers  have  estimated  it,  in  rare  instances,  as  one  or  two 
pints. 

There  are  otiier  discharges  of  blood,  coming  from  the  neck  of  the 
bladder,  which  take  place  in  cases  of  gonorrh'cal  cystitis.  These  will  be 
mentioned  hereafter. 

There  are  other  important  complications  of  the  inflammatory  stage  of 
gonorrhoea,  such  as  inflammation  of  the  corpora  cav(!ruosa,  folliculitis, 
periurethral  abscess,  lymphangitis,  adenitis,  etc.  etc.,  which  are  worthy  of 


SYMPTOMS.  39 

careful  study,  but  wliicli  will  be  best  treated  of  in  subsequent  chapters,  to 
which  the  reader  is  referred. 

The  second  stage  of  gonorrhoea,  which  we  have  now  described,  is  vari- 
a1)le  in  its  duration  in  different  subjects.  As  a  general  rule,  it  lasts  from 
one  to  tliree  weeks,  being  influenced  by  the  constitution  of  the  individual, 
his  mode  of  life,  and  the  number  of  his  previous  attacks.  It  is  succeeded 
by  the  third  stage  or  stage  of  decline.  This  final  stage  of  gonorrh<ea  is 
characterized  only  by  the  disappearance  of  the  more  acute  symptoms  and 
a  gradual  return  to  a  condition  of  health.  The  discharge  runs  through  the 
same  phases,  in  an  inverse  order,  which  it  did  at  the  outset  of  the  attack. 
It  gradually  becomes  less  and  less  purulent,  and  finally  is  almost  wholly 
mucous,  before  completely  disa[)pearing. 

Perhaps  the  most  valuable  indication  of  the  ushering  in  of  this  stage  of 
gonorrhoea  is  the  marked  diminution  or  entire  cessation  of  the  pain  in  pass- 
ing water.  The  painful  erections  and  chordee  may  continue  after  the 
acute  inflammation  has  subsided,  since  it  takes  time  for  tlie  i)lastic  matter 
effused  around  the  urethra  to  be  absorbed. 

We  have  reason  to  believe  that  in  the  course  of  an  attack  of  gonorrhoea, 
the  disease  gradually  extends  from  the  outer  to  the  deeper  portions  of  the 
canal,  and  it  is  in  this  latter  situation  that  it  is  prone  to  lurk  for  an  indefi- 
nite period.  After  the  discharge  has  lasted  for  several  weeks,  we  may 
evacuate  the  whole  of  the  spongy  portion  by  pressure  from  behind  forward 
in  front  of  the  scrotum,  and  then,  when  no  further  discharge  can  be  made 
to  appear,  we  can  still  produce  it  by  the  exercise  of  similar  pressure  on 
tlie  perinieum. 

The  duration  of  the  final  stage  of  gonorrhoea  is,  as  a  general  rule,  longer 
than  either  of  the  preceding.  It  may  be  cut  short  by  treatment,  but,  if 
left  to  itself,  commonly  lasts  for  weeks  or  even  montlis.  Gonoi-rhfca  is  a 
disease  which,  independently  of  treatment,  rarely  terminates  in  less  than 
three  months. 

Thus  far  I  have  said  nothing  of  the  reaction  of  this  disease  upon  the 
general  system.  This  varies  greatly  in  different  individuals  and  in  dif- 
ferent attacks  in  the  same  ])erson.  In  some  rare  cases  there  is  consider- 
able febrile  excitement  during  the  inflammatory  stage,  marked  by  the 
usual  symptoms  of  headache,  dry  skin,  full  pulse,  furred  tongue,  etc.  As 
a  general  rule,  however,  there  is  but  little  constitutional  disturbance,  and 
after  the  acute  symptoms  have  passed,  the  invariable  tendency  of  tlie  dis- 
ease is  to  depress  the  general  health.  This  fact  should  be  remembered  in 
the  treatment. 

A  first  attack  of  gonorrluea  is  usually  more  acute  than  subsequent  ones; 
tjie  latter  often  being  sul)acute  or  chronic  from  the  first.  They  are  also 
more  diflicult  to  be  infiuenced  by  remedies,  and  show  a  decided  tendency 
to  run  into  gleet. 

Cases  of  gonorrluca  have  been  reported,  in  which  it  has  been  said  there 
was  no  discharge  whatever — all  the  other  symptoms  of  gonorrhoea  being 
,j)resent,  and  the  disease  following  impure  coitus.  These  have  been  called 
cases  of  dry  gonorrhoea.     I  doubt  whether  there  be  a  total  absence  of  all 


40  URETHRAL    GONORRHffiA    IN    THE    MALE. 

secretion  in  these  eases  throiigliout  tlieir  whole  course,  but  can  readily  con- 
ceive of  an  inflammation  of  the  mucous  membrane  of  the  urethra,  resem- 
bling that  of  erysipelas  upon  the  skin,  in  which  the  secretion  is  for  a  time 
but  slight,  and  incapable  of  detection  except  by  a  careful  examination  of 
the  urine.  As  the  inflammation  subsides,  however,  I  should  expect  to  find 
distinct  traces  of  a  discharge.  We  have  analogous  symptoms  occasionally 
in  inflammations  of  the  pituitary  membrane  of  the  nose.  Two  cases  of 
this  variety  of  gonorrhoea  are  rejiorted  by  Dr.  Beadle  in  the  Netv  York 
Journal  of  Medicine  and  Surgery,  for  October,  1840. 

Causes   and  Nature  of   Gonorrhcea Every  one  is  aware  that 

urethral  gonorrha?a  in  the  male  often  proceeds  from  direct  contagion,  or, 
in  other  words,  from  intercourse  with  a  woman  affected  with  the  same  dis- 
ease. But  there  is  another  mode  of  origin,  admitted  by  nearly  every  wri- 
ter, as  of  at  least  occasional  occurrence,  but  with  regard  to  the  frequency 
of  which  some  difference  of  opinion  has  been  expressed.  I  refer  to  gonor- 
rhoea originating  in  coitus  just  before,  after,  or  during  the  menstrual 
period,  or  with  a  woman  suffering  from  leucorrhtea,  and,  in  a  few  in- 
stances, when  nothing  whatever  abnormal  can  be  discovered  in  the  female 
genital  organs,  and  the  disease  in  the  male  can  only  be  attributed  to  the 
irritant  character  of  the  vaginal  or  uterine  secretions,  or  to  excessive  coitus 
often  combined  with  the  influence  of  alcoholic  stimulants. 

I  have  been  convinced,  by  a  somewhat  extended  observation,  tliat  gon- 
orrhoea originating  in  this  mode  is  of  very  frequent  occurrence.  Of  one 
thing  I  am  absolutely  certain,  that  gonorrhfca  in  the  male  may  proceed 
from  intercourse  with  a  w'oman  with  whom  coitus  has  for  months,  or  even 
years,  been  practised  with  safety,  and  this,  too,  without  any  change  in  the 
condition  of  her  genital  organs,  perceptible  upon  the  most  minute  exami- 
nation with  the  speculum.  I  am  constantly  meeting  with  cases  in  which 
one  or  more  men  have  cohabited  with  impunity  with  a  woman  both  before 
and  after  the  time  when  she  lias  occasioned  gonorrhoea  in  another  person ; 
or,  less  frequently,  in  which  the  same  man,  after  visiting  a  woman  for  a 
long  period  with  safety,  is  attacked  with  gonorrhoea  without  any  disease 
apiiearing.in  her,  and  after  recovery  resumes  his  intercourse  with  her  and 
experiences  no  farther  trouble.  The  frequency  of  such  cases  leaves  no 
doubt  in  my  mind,  that  gonorrhoea  is  often  due  to  accidental  causes,  and 
not  to  direct  contagion. 

In  many  of  the  instances  referred  to,  the  woman  is  suffering  from  a 
frequent  combination  of  symptoms  met  witli  in  practice,  viz.,  general  de- 
bility, engorgement  of  the  cervix  uteri,  and  more  or  less  leucorrhoca ;  but 
her  previous  history,  and  the  impunity  with  which  her  favors  have  been 
bestowed  for  a  long  period,  preclude  the  idea  that  her  discharge  is  the  re- 
mains of  a  ]irevious  attack  of  gonorrlnea  to  which  it  owes  its  contagious 
property.  Moreover,  such  an  ex})lanation  fails  to  cover  other  instances, 
in  which  there  is  no  appearance  whatever  of  leucorrhoca,  and  the  genital 
organs,  so  far  as  we  can  discover,  are  in  a  state  of  perfect  health  ;  although 


CAUSES    AND    NATURE    OF    GONORRH(EA.  41 

intercourse  about  the  time  of  the  menstrual  period  has  given  rise  to  gonor- 
rhrea  in  the  male. 

The  greatest  obstacle  to  the  admission  of  gonorrhoea  independent  of 
contagion  appears  to  be  the  rarity  of  urethritis  in  married  men  compared 
Avith  the  frequency  of  leucorrhoeal  discharges  in  their  wives.  As  proved 
by  unquestionable  cases  occurring  in  my  own  practice  and  in  that  of  my 
medical  friends,  husbands  do  not  always  escape.  That  they  are  not  more 
frequently  aifected  is  sufficiently  explained  by  the  immunity  conferred 
against  all  simple  irritants  by  constant  and  repeated  exposure,  whereby 
"  acclimation" — to  use  a  term  adopted  by  the  French— ^is  acquired.  The 
same  fact  is  observed  when  neither  the  church  nor  the  state  has  sanctioned 
marital  relations ;  since  it  is  not  generally  the  liabitual  attendant  upon  a 
kept  mistress  affected  with  leucorrhoea  who  suffers,  but  some  fresh  comer 
who  shares  her  favors  for  the  first  time. 

My  friend,  Dr.  B.  Fordyce  Barker,  whose  extensive  experience  with 
female  diseases  is  well  known,  and  who  has  thus  had  the  opportunity  of 
studying  this  subject  from  an  opposite  standpoint  to  my  own,  tells  me  that 
lie  has  noticed  a  peculiar  form  of  inflammation  of  the  lining  membrane  of 
the  uterus,  in  which  the  uterine  discharge  loses  its  alkaline  reaction,  be- 
comes decidedly  acid  and  acrid,  and  irritates  and  excoriates  the  mucous 
membrane  of  tlie  vagina  and  the  surface  of  the  vulva.  He  adds,  tliat,  in 
numerous  instances  in  married  life,  he  lias  known  this  discharge  to  excite 
urethritis  in  the  male  between  parties  whose  fidelity  was  unquestionable  ; 
and  he  has  related  to  me  a  number  in  detail  which  I  would  gladly  repeat, 
if  space  permitted. 

]Most  Ciises  of  gonorrhoea  from  leucorrhoea  or  the  menstrual  fluid  present 
no  cliaracteristic  symptoms  by  which  they  can  be  distinguished  from  those 
originating  in  contagion.  The  contrary  is  frequently  asserted,  and  it  is 
said  tliat  the  former  class  may  be  recognized  by  the  mildness  of  the  symp- 
toms, the  short  duration  of  the  disease,  and  the  absence  of  contagious  pro- 
perties. I  am  familiar  with  the  slight  urethral  discharge  unattended  by 
symptoms  of  acute  inflammation,  and  disappearing  spontaneously  in  a  few 
days,  which  sometimes  follows  intercourse  with  women  affected  with  leu- 
corrhoea;  but  such  instances  are  far  less  frequent  than  those  in  which  the 
disease  is  equally  as  persistent  and  as  exposed  to  complications  as  any 
case  of  gonorrhoea  from  contagion.  Some  of  the  most  obstinate  cases  of 
uretlu-itis  I  have  ever  met  with  have  been  of  leucorrhoeal  origin,  and  have 
terminated  in  gleet  of  many  montiis'  duration.  Diday  has  even  set  apart 
tliose  cases  of  urethritis  which  originate  in  the  m(;nstrual  fluid  as  consti- 
tuting a  distinct  class,  characterized  by  their  greater  persistency  and  ob- 
stinacy under  treatment  than  cases  of  gonorrhrca  from  contagion.' 

Tliose  who  maintain  the  non-contagious  character  of  urethral  discharges 
of  leucorrho'al  origin  liave  failed  to  adduce  the  sliglitest  proof  in  favor  of 
tlieir  assumption,  and  it  may  safely  be  asscrtcid  tli;it  none  of  them  would 
venture  to  make  a  practical  ai)plication   of  their   principles.     The  conta- 

'  Arch.  ''en.  iiied.,  Oct.  18(J1. 


42  URETHRAL    GONORRIKEA    IN    THE    MALE. 

gious  character  of  the  leucorrhoeal  secretion  is  already  proved  by  the  ex- 
istence of  the  disease  in  the  male  ;  why  should  not  the  same  property  be 
continued  another,  still  another,  and  any  number  of  removes  from  its 
origin  ?  Tiiis  supposition  is  sustainetl  by  analogy,  since  no  fact  is  better 
established  than  that  catarrhal  conjunctivitis,  or  vulvitis  in  young  girls, 
originating,  for  instance,  from  ascarides  in  the  rectum,  may  be  communi- 
cated from  one  person  to  another  until  all  the  members  of  a  family,  school, 
or  asylum  have  become  aifected.  At  our  public  institutions  for  diseases 
of  the  eye  such  instances  are  very  common,  and  the  physicians  of  our 
children's  asylums,  are  well  aware  of  tlie  difficulty  of  eradicating  muco- 
purulent conjunctivitis  wliich  has  once  sprung  up  among  the  inmates.  At 
an  orphan  asylum  under  the  charge  of  my  friend.  Dr.  Leaming,  this  dis- 
ease was  introduced  by  a  single  child,  brought  from  Randall's  Island,  and 
spread  to  twenty-two  others  before  it  could  be  arrested.  Again,  the  leu- 
corrlujca  of  pregnancy  is  sufficient  to  give  rise  to  ophthalmia  neonatorum  : 
would  any  one,  presuming  upon  its  leucorrhoeal  origin,  dare  to  apply  a 
drop  from  the  infimt's  eyes  to  his  own?  Several  instances  are  recorded 
in  which  physicians  have  lost  the  sight  of  an  eye  with  which  the  discharge 
of  ophthalmia  neonatorum  has  inadvertently  been  brought  in  contact. 
]My  friend,  Prof.  F.  N.  Otis,  has  taken  pus  from  the  eye  of  a  child  suffer- 
ing from  acute  ophthalmia,  and  injected  it  into  the  urethra  of  an  adult, 
with  the  effect  of  producing  a  gonorrh'jea  "  which  continued  for  four  or 
five  weeks,  and  was  attended  by  the  ordinary  complications  of  cedema, 
chordee,"  etc. 

The  views  which  I  have  here  advocated  relative  to  the  frequency  of 
gonorrhoea  independent  of  contagion,  are  by  no  means  novel,  and  are  en- 
tertained by  many  of  our  most  eminent  authorities,  especially  among  the 
French,  wlio  possess  unequal  advantages  for  investigating  the  etiology  of 
venereal  diseases.^ 

Thus,  to  quote  from  Fournier:  "Ricord  says,  'women  frequently  give 
gonorrhoea  without  having  it;'  in  my  (Fournier's)  opinion  he  should  have 
said  most  frequently.  For  one  case  of  gonorrluxsa  resulting  from  contagion, 
there  are  at  least  three  in  which  contagion,  strictly  speaking,  plays  no 
part.  From  my  own  observations,  I  conclude  that  the  man  is  oftener 
responsible  for  his  gonorrluca  than  the  woman  from  whom  he  seems  tO'  get 
it;  he  gives  himself  the  clap  oftener  than  he  receives  it." 

The  importance  of  this  truth  whenever  a  physician  in  the  exercise  of  his 
profession  incurs  the  fearful  responsibility  of  passing  judgment  upon  the 
virtue  of  a  woman,  and  thus  affecting  her  reputation  and  happiness  (and 
often  that  of  many  others  with  whom  she  is  connected)  for  life,  cannot  be 

■  Consiilt  RicoKD  :  Lettres  sur  la  sypliilis,  2d  edition,  p.  29.  Diday  :  Nouvelles 
doctrines  sur  la  syphilis,  p.  f)\f>.  Foi'rxikii  :  De  la  contagion  syphilitique,  p.  111. 
Sir  Henry  Thompson  :  Stricture  of  the  Uretlira,  p.  120.  Mr.  Skey  :  London  Medical 
Gazette,  vol.  xxiii  (1838-39),  i>.  439.  Berkeley  Hii,l  :  Syphilis  and  Local  Con- 
tagious Disorders,  p.  376.  Guilland  :  Des  manifestations  du  rlieuniatisrne  sur 
Turethre  et  la  vessie,  1876,  p.  4.  Otis  :  Clinical  Lecture,  Med.  Record,  N.  Y., 
May  18,  1878. 


CAUSES  AND  NATURE  OF  GONORRH(EA.  43 

overrated.  In  all  such  cases,  the  accused  should  receive  the  benefit  of 
any  doubt  which  may  exist;  and  the  physician  who  withholds  it  from  her 
out  of  a  morbid  fear  that  he  may  be  imposed  upon,  and  thus  runs  the  risk 
of  convicting  an  innocent  person,  is  unworthy  of  his  calling.  His  province 
is  to  decide  from  the  symptoms  taken  in  connection  with  the  known  facts 
of  the  case,  and  unless  these  are  sufficient  to  establish  guilt  beyond  the 
shadow  of  a  doubt,  humanity  demands  at  least  a  verdict  of  "not  proven." 

Other  causes,  in  addition  to  those  already  mentioned,  may  give  rise  to 
urethral  gonorrhoea  in  the  male.  Thus,  unquestionable  instances  are  re- 
ported in  which  a  gouty  or  rheumatic  diathesis  without  exposure  in  sexual 
intercourse  has  occasioned  a  discharge  from  tlie  urethra.  Dr.  Guilland 
has  collected  a  number  of  such  published  cases,  with  the  addition  of  others 
of  his  own.  In  two  of  them,  the  patients  had  never  had  intercourse  with 
women,  so  that  the  urethral  discharge  following  an  attack  of  rheumatism 
could  not  be  looked  upon  as  a  mere  coincidence.  In  other  patients,  one 
of  them  an  interne  in  the  Paris  hospitals,  and  all  of  them  of  a  rheumatic 
diathesis,  too  long  a  time  had  elapsed  since  the  last  act  of  coitus  to  ascribe 
the  urethritis  to  contagion. 

To  finish  Avith  this  subject  of  rheumatic  gonorrhoea,  I  will  here  give 
Guilland's  resume  of  its  characteristic  features,  italicizing  those  which  he 
appears  to  regard  as  of  the  most  importance:  "  Discharge  copious,  appear- 
ing suddenly  and  attended  with  little  pain ;  disappears  in  most  cases  spon- 
taneously after  a  comparatively  short  duration ;  general  disturbance  of 
the  system  frequent;  coexistence  of  rheumatic  symptoms,  or  at  least  his- 
tory of  this  diathesis.     Above  all,  absence  of  any  chance  of  contc(gion." 

Ricord  relates  a  remarkable  case  of  tubercular  deposit  in  different  por- 
tions of  the  urethra  of  a  strumous  subject  with  symptomatic  urethral  dis- 
charge;^ and  a  scrofulotis  diathesis  is  generally  a  strong  predisposing,  if 
not  an  active  cause  of  inflammation  of  the  urethra  as  well  as  other  mucous 
canals. 

]Mr.  Harrison  rej)orts  the  case  of  a  medical  practitioner  who  suffered 
from  a  puriform  discliarge,  heat  and  pain  along  tlie  course  of  the  urethra, 
attended  with  frequent  micturition,  chordee,  and  sympathetic  fever,  after 
eating  largely  of  asparagus.^ 

It  is  also  claimed  that  arsenic,  when  producing  a  toxic  effect  either  in 
consequence  of  the  amount  of  the  dose  or  tlie  peculiar  susceptibility  of  the 
patient,  will  act  upon  tlie  urethral  mucous  membrane  in  a  similar  manner 
as  it  does  upon  the  digestive  tract  and  upon  the  skin,  and  cause  urethritis. 
Two  such  cases  are  reported  by  M.  Saint-Philippe.^ 

Among  other  causes  of  urethritis  are  free  indulgence  in  fermented 
liquors,  terebinthinate  medicines,  para|)legia  inducing  changes  in  the 
urine,  the  use  of  bougies,  stricture,  masturljation,  prolonged  excitement  of 
the  genitals,  cancer  of  the  womb,  vegetations  within  the  un.'thra,  ascarides 

'  Bull.  Acad,  fie  med.,  Par.,  vol.  xv,  p.  ."iGS. 

*  Lancet,  London,  Am.  e(L,  Jan.,  1800. 

*  Lend.  M.  Record,  May  15,  1878,  from  tlie  Gaz.  m^d.  de  Bordeaux. 


44  URETHRAL    GONORRHCEA    IN    THE    MALE. 

in  the  rectum,  dentition,  epidemic  influences,  etc.  The  internal  use  of 
cantharides  is  peculiarly  liable  to  excite  gonorrhoea,  which,  in  this  case, 
commences  in  the  deeper  portion  of  the  canal. 

M.  Latour,  editor  of  the  Union  medicale,  vouches  for  the  truth  of  tlie 
following  story  :  A  physician,  thirty  years  of  age,  had  been  continent  for 
more  than  six  weeks,  when  he  passed  an  entire  day  in  the  presence  of  a 
woman  whose  virtue  he  vainly  attempted  to  overcome,  but  who  resisted 
all  his  approaches.  From  ten  o'clock  in  the  morning  until  seven  in  the 
evening,  his  genital  organs  were  in  a  constant  state  of  excitement.  Three 
days  afterwards  he  was  seized  with  a  very  severe  attack  of  gonorrlicea, 
which  lasted  for  forty  days. 

A  chancre  within  the  urethra  is  attended  with  more  or  less  thin  and 
often  bloody  discharge,  which  will  be  more  particularly  described  in  a 
subsequent  portion  of  this  work. 

Again,  urethral  discharges  are  sometimes  due  to  changes  in  the  mucous 
membrane  lining  the  canal,  induced  by  infection  of  the  constitution  with 
the  syphilitic  virus.  In  several  instances  I  have  observed  a  muco-purulent 
discharge  coinciding  with  the  first  outbreak  or  a  relapse  of  secondary 
symptoms,  and  so  long  after  the  last  sexual  act  that  it  could  not  be  attri- 
buted to  the  ordinary  causes  of  gonorrhoea.  Bassereau  speaks  of  similar 
cases.^  There  is  no  more  frequent  seat  of  early  general  manifestations 
than  the  mucous  membranes  in  general  ;  and  in  the  cases  referred  to 
changes  probably  take  place  in  the  urethral  walls  similar  to  the  erythema, 
mucous  patches,  and  superficial  ulcerations  which  are  found  within  the 
buccal  and  nas.il  cavities.  These  cases  are  very  rare,  and  can  only  be  dis- 
tinguished from  ordinary  gonorrhcjea  by  the  previous  history  and  coexist- 
ing symptoms  of  the  patient.  For  instance,  if  there  has  been  no  exposure 
for  a  long  period,  and  especially  if  secondary  symptoms  have  recently  made 
their  appearance  upon  other  mucous  membranes,  the  urethral  discharge  is 
probably  symptomatic  of  the  constitutional  disease.  Since  the  secretions 
of  secondary  lesions  are  now  known  to  be  contagious,  the  discharge  in 
these  cases  is  doubtless  so,  also  ;  it  is  not  readily  inoculated  upon  the  person 
from  whom  it  is  derived  nor  upon  any  other  affected  with  syphilis,  but,  if 
communicated  to  a  healthy  individual  under  the  requisite  conditions,  it 
may  give  rise  to  a  cliancre. 

Kicord's  receipt  for  catching  the  clap  may  show  how  to  avoid  it :  "  Do 
you  want  to  catch  a  dap?  I  will  tell  you  how  to  do  it.  Select  some 
woman  of  a  pale  lymphatic  temperament — a  blonde  is  better  than  a  bru- 
nette— and  the  more  'whites'  she  has  the  better.  Take  her  out  to  dine; 
order  oysters  first,  and  don't  forget  asparagus  afterwards.  Di'ink  often 
and  freely — white  wines,  champagne,  coffee,  liqueurs,  they  are  all  good. 
After  dinner  dance  a  while,  and  have  your  friend  dance  with  you.  Get 
well  heated  during  the  evening,  and  quench  your  thirst  without  stint  with 
beer.  At  night  play  your  part  valiantly  ;  two  or  three  times  are  not  too 
much,  but  more  would  be  better.     The  next  morning  do  not  forget  to  take 

'  Affections  sjphilitiques  de  la  in'au,  p.  35G. 


CAUSES    AND    NATURE    OF    GONORRHCEA.  45 

a  prolonged  hot  bath  ;  moreover,  do  not  omit  to  take  an  injection.  This 
programme  having  been  conscientiously  followed  out,  if  you  don't  have  a 
clap  some  good  Deity  must  have  saved  you." 

Fournier's  statistics  as  to  the  class  of  women  from  whom  gonorrhoea  is 
most  frequently  derived  are  interesting: — 

Public  prostitutes        ........       12 

Clandestine  prostitutes       .......       44 

Kept  womeu,  actresses         .         .         .         .         .         .         .138 

Shop  girls 126 

Domestics  .........       41 

Married  women  .........       2fj 

387 

This  table  simply  shows  what  daily  observation  corroborates,  that  there 
is  not  so  much  safety  in  what  fast  young  men  call  '•  a  good  thing"  as  they 
believe  ;  in  other  words,  that  more  claps  are  caught  in  "  nice  little  arrange- 
ments" than  in  brothels. 

The  inferences  from  what  has  now  been  said  of  tlie  etiology  of  gonor- 
rhoea relative  to  its  nature,  are  so  obvious  that  they  require  little  more 
than  mere  mention.  If  in  a  large  proportion  of  cases  the  disease  can  be 
tiaced  to  no  other  cause  than  leucorrhoea,  the  menstrual  fluid,  to  excessive 
coitus,  intercourse  under  circumstances  of  special  excitement,  inattention 
to  cleanliness,  the  abuse  of  stimulants,  etc.,  and  if,  when  thus  originating, 
it  is  undistinguishable,  either  by  its  symptoms,  course,  complications,  or 
termination,  from  the  same  affection  due  to  contagion,  it  is  evident  that  it 
should  be  ranked  among  the  ordinary  catarrhal  inflammations  of  mucous 
membranes,  or,  in  otlier  words,  that  it  is  a  simple  urethritis,  the  connection 
of  which  with  sexual  intercourse  is  a  merely  accidental,  or  at  all  events, 
not  a  necessary  circumstance. 

But — it  may  be  asserted — the  possibility  of  contagion  proves  the  pres- 
ence of  a  poison.  Granted  :  but  it  does  not  follow  that  it  is  a  specific 
poison,  or  one  incapabhi  of  being  produced  by  sim[)le  inflammation.  Such 
a,  conclusion  would  be  contrary  to  the  facts  adduced  in  the  preceding  pages, 
and,  moreover,  is  not  required  by  the  analogy  of  inflammations  of  other 
mucous  membranes  ;  since,  in  muco-purulent  conjunctivitis — tlie  true  ana- 
logue of  (jonorrhoea — we  have  precisely  the  same  order  of  events,  viz., 
inflammation  origiiuiting  in  simple  causes,  and  giving  rise  to  a  secretion 
which  is  contagious  and  capable  of  transmission  through  an  indefinite 
series  of  individuals.  The  discharge  from  the  two  mucous  surfaces  just 
mentioned  would  even  a[)pear  to  be  transferable,  since  that  from  the  urethra 
applied  to  the  eye  gives  rise  to  purulent  ophthalmia,  the  secretion  of  whicli, 
Pi'  we  may  rely  upon  a  few  experiments  by  Thiry,  of  Brussels,  will,  wiien 
brought  in  contact  with  the  lining  membrane  of  tlie  urethra,  produce  ure- 
thritis. 

Base<l  upon  the  fact  that  patches  of  granulations  exist  upon  tlie  urethral 
mucous  membrane  in  most  old    cases  of   gonorrhtca,  a  theory  has  been 


46  URETHRAL    GONORRHCEA    IN    THE    MALE. 

offered  by  M.  Thiry^  to  the  effect,  that  tliese  excrescences  are  the  essential 
element  of  contagion  ;  without  granulations,  no  contagion.  Tliis  view  is 
apparently  indorsed  by  Desormeaux,  but  is  untenable. 

Lesions The  pathological  changes  which  take  place  in  a  case  of  gonor- 

rhcea  consist  chicHy  in  hypertemia  of  the  urethral  mucous  membrane,  with 
its  attendant  swelling  and  increased  sensibility.  The  disease  travels  from 
the  outer  to  the  deeper  parts  of  the  canal,  and,  according  to  Desormeaux, 
has  by  the  eighth  day  involved  the  anterior  half,  over  which  the  mucous 
membrane  is  found  to  be  reddened,  rougliened,  and  presenting  the  appear- 
ance of  superficial  ulcerations  like  those  observed  upon  the  glans  in  cases 
of  balanitis.  These  changes  remain  tl>e  same  at  a  more  advanced  stage, 
but  involve  the  deeper  parts  of  the  passage,  as  the  membranous  and  even 
prostatic  portions.  True  ulcerations  involving  the  whole  thickness  of  the 
mucous  membrane  are  not  met  with. 

The  follicles  opening  into  the  urethra  are  often  attacked  as  well  as  tlie 
glands  themselves,  and  are  found  filled  with  pus.  In  old  cases,  the  mucous 
membrane  becomes  thickened,  and  of  greater  density.  The  subjacent 
tissues  do  not  escape,  and  the  areoli  of  the  s[)ongy  tissue  are  filled  up  and 
effaced.  With  the  lapse  of  time,  the  inflammation  disappears  from  a  great 
portion  of  the  canal  and  limits  itself  to  certain  points,  of  which  the  most 
frequent  is  the  bulbo-membranous  I'egion.  These  present  a  granular  sur- 
face or  even  fungous  elevations,  and  in  rare  instances,  sessile  or  pediculated 
veo-etations.  The  mucous  membrane  may  be  several  times  its  normal 
thickness,  firm,  hard,  and  horny.  Bands  are  sometimes  found,  stretching 
from  one  side  to  the  other.  The  orifices  of  the  glands  may  be  obliterated 
or,  in  other  cases,  markedly  dilated.  To  these  changes  should  be  added 
those  which  take  place  in  the  neighborhood  of  any  stricture  that  may  have 
formed,  and  which  will  be  considered  hei'eafter. 

Since  granulations  of  the  mucous  membrane  are  one  of  the  chief  things 
souo'ht  for  in  examinations  with  the  endoscope,  and  since  so  much  stress 
has  been  laid  upon  their  presence,  a  fuller  account  of  them  is  desirable. 

The  following  is  from  Desormeaux, '■*  being  the  result  of  his  endoscopic 
examinations:  "We  have  seen  that  gonorrhoea,  when  passing  into  the 
chronic  stage,  limits  itself  to  the  bulbo-membranous  portion  of  the  urethra, 
and  that  the  mucous  membrane  of  this  part,  at  first  simply  dei)rived  of  its 
lustre,  soon  becomes  uneven.  These  inequalities  increase,  multiply,  and 
finally  form  rounded  hemispherical  projections  (granulations).  Then  the 
diseased  portion  j)resents  a  surface  of  a  deep  red  color,  uneven,  scattei'cd 
over  with  round  granulations,  which  are  sometimes  a  little  removed  from 
each  other  and  at  other  times  closely  opposed.  The  mucous  membrane 
in  the  affected  portion  looks  like  a  mulberry,  both  in  its  color  and  its 
granular  surface. 

"  The  granulations  vary  in  size  from  that  of  a  mustard  seed  to  a  millet 

J  M.  Tiiiry's  views  have  been  published  in  a  series  of  lectures  in  the  Prcsse 
med.  beige,  Brux.,  aud  are  also  advocated  by  Guyomar,  These  de  Paris,  1858  (No. 
282). 

2  De  I'eiidoscope,  etc.,  1865,  j).  40. 


TREATMENT.  47 

or  even  hemp  seed.  The  smallest  appear  to  be  of  newest  formation.  This 
lesion  is  a  perfect  resemblance  of  the  granulations  found  on  the  uterine 
neck  and  on  the  ocular  conjunctiva.  The  granulations  are  almost  always 
of  a  more  or  less  deep  red,  and  often  of  a  dregs-of-wine  color ;  but  in  some 
cases  I  have  found  in  the  midst  of  them  other  granulations,  less  numerous, 
small,  and  of  a  grayish  color. 

"These  granulations  may  occupy  a  greater  or  less  extent  of  the  canal, 
most  frequently  about  an  inch  to  an  inch  and  a  half.  Sometimes  they  in- 
volve the  whole  of  the  posterior  portion,  from  the  end  of  the  spongy  urethra 
to  the  vesical  neck.  An  almost  constant  character  is  that  the  lesion  is 
unique;  it  does  not  spread;  there  is  no  interruption  between  its  two  ex- 
ti'emities ;  we  do  not  find  isolated  patches,  separated  by  portions  of  sound 
membrane.  There  is  only  one  patch,  befoi-e  and  behind  which  there  is 
some  inflammatory  redness  gradually  shading  off  into  sound  tissue." 

Desormeaux,  Tarnowski,  and  others  also  describe  herpetic  patches  in 
the  canal,  which  are  to  be  distinguished  from  the  foregoing.  "These 
patches  of  herpes  correspond  exactly  to  those  observed  on  the  skin,  on  the 
lips,  and  on  the  neck  of  the  uterus.  They  are  generally  multiple  and  are 
found  at  different  points  of  the  canal.  They  have  the  same  fugacious  and 
mobile  character  as  the  ulcerations  of  the  same  nature  met  with  in  the 
mouth.  A  patch  found  to-day  may  be  absent  to-morrow,  when  others  will 
be  found  in  other  places.  Tliey  again  differ  from  granulations  in  that 
they  occupy  generally  a  much  less  extent.  Finally,  tl)eir  aspect  is  quite 
different ;  their  surface  is  not  granular,  it  is  often  merely  deprived  of  its 
ordinary  lustre  {d'cpolU)  like  the  aphthaj  on  the  internal  surfjxce  of  the 
cheeks,  or  like  the  [jatches  denuded  of  epithelium  that  are  frequently  met 
with  on  the  buccal  mucous  membrane  of  smokers. 

"We  meet  with  still  another  form  of  herpetic  urethritis,  apparently  of  a 
deeper  character.  The  ulcerations  which  it  presents  are  less  variable  in 
their  seat;  they  are  uneven  in  their  outline,  and,  were  it  not  for  accessory 
circumstances,  one  would  be  tempted,  on  superficial  examination,  to  regard 
tliera  as  gonorrhoeal  ulcerations  in  the  reparative  stage;  but,  with  a  little 
attention,  we  find,  that  instead  of  projections,  the  inequalities  of  the  surface 
are  due  to  depressions.  Hence,  while  a  granular  surface  may  be  compared 
to  that  of  a  mulberry,  tlje  former  resembles  the  depressions  on  the  skin  of 
an  orange  or  the  head  of  a  thimble. 

"Granular  urethritis  pursues  an  essentially  clironic  course  and  leads 
fatally  to  stricture.  Herpetic  urethritis  is  more  under  the  influence  of 
changes  in  the  season,  which  control  tlie  evolution  of  rheumatic  affections. 
The  persistence  of  granuhitions  on  the  one  hand  and  the  liability  to  her- 
petic eruptions  on  the  other  will  explain  why  so  many  men  have  repeated 
attacks  of  gonorrhoea  upon  the  slightest  exposure." 

Trkatmext The  treatment  of  gonorrhcjua   must  be  a(hipted   to  the 

general  condition  of  the  patient,  and  especially  to  the  stage  of  his  disease. 
In  the  great  majority  of  cases  met  with  in  practice,  acute  inflammatory 
symptoms  have  already  set  in  at  the  time  the  patient  first  applies  to  the 


48  URETHRAL    GONORRIICEA    IN    THE    MALE 

surgeon ;  but  in  tliose  exceptional  cases  Avhich  are  seen  at  an  early  period, 
and  ill  those  only,  we  may  often  succeed  in  cutting  short  the  disease  by 
means  of  the  treatment  termed  abortive. 

Abortive  Treatment  of  the  First  Stage. — During  the  first  few  days  after 
exposure,  varying  in  number  from  one  to  five  in  ditierent  cases,  before  the 
symptoms  have  become  acute,  when  the  discharge  is  but  slight  and  chiefly 
mucous,  and  while  as  yet  there  is  no  severe  scalding  in  passing  water,  we 
may  resort  to  caustic  injections  with  a  view  of  exciting  artificial  inflam- 
mation wdiich  will  tend  to  subside  in  a  few  days,  and  supplanting  the 
existing  morbid  action  which  is  liable  to  continue  for  an  indefinite  period 
and  is  exposed  to  various  complications.  This  is  known  as  tlie  "  substi- 
tutive," or  more  commonly  as  the  "abortive  treatment"  of  gonorrhoea. 
This  method  has  been  inordinately  praised  and  as  violently  attacked  ;  its 
true  merit  is  probably  to  be  found  between  these  two  extremes.  It  is 
certainly  liable  to  be  greatly  abused,  and,  if  so,  is  both  unsuccessful  and 
capable  of  producing  the  most  unpleasant  consequences  ;  but  when  limited 
to  the  early  stage  of  gonorrhoea  and  used  with  ]iroper  caution,  it  is  a 
highly  valuable  method  of  treatment,  unattended  with  danger,  and  unde- 
serving the  censure  sometimes  cast  upon  it. 

In  employing  the  abortive  treatment,  there  are  several  points  which  it 
is  important  to  recollect :  1.  The  disease,  in  the  stage  to  which  this  treat- 
ment is  ai)plicable,  is  limited  to  the  anterior  portion  of  the  urethra,  known 
as  the  fossa  navicularis,  or  extends  but  a  short  distance  beyond  it ;  it  is 
not  necessary,  therefore,  that  the  injection  should  reach  the  deeper  por- 
tions of  the  canal.  2.  For  the  treatment  to  be  successful,  the  whole  dis- 
eased surface  should  receive  a  thorough  application  of  the  injection,  for  if 
any  portion  remain  untouched,  it  will  secrete  matter  that  will  again  light 
up  the  disease.  3.  When  once  a  sufficient  degree  of  artificial  inflammation 
is  excited,  the  caustic  has  accomplished  all  that  can  be  expected  of  it,  and 
should  be  suspended. 

Since  a  solution  of  nitrate  of  silver,  which  is  commonly  used  in  the 
abortive  treatment,  is  readily  decomposed  by  contact  with  metallic  sub- 
stances, metal  syringes  should  be  avoided.  Glass  syringes,  if  well  made, 
answer  every  purpose  ;  but  as  found  in  the  shops,  they  are  apt  to  be  un- 
equal in  calibre  in  different  parts  of  the  cylinder,  the  wadding  of  the 
piston  contracts  in  drying,  and  a  portion  of  the  fluid  fails  to  be  thrown 
out,  as  is  seen  by  its  overflow  wlien  the  syringe  is  filled  a  second  time. 
For  these  reasons,  I  never  advise  a  patient  to  purchase  an  ordinary  glass 

Fig.  1. 


syringe,  knoAving  that  it  will  probably  give  him   much  annoyance,  and 
perhaps  prevent  his  deriving  benefit  from  treatment.     AVe  have  an  excel- 


TREATMENT. 


49 


lent  substitute  in  the  hard-rubber  syringes  which  can  be  obtained  at  the 
druggists. 

"  No.  1"  (Fig.  1)  is  tlie  one  generally  sold  when  no  special  form  is  di- 
rected by  the  surgeon,  but  its  nozzle  is  objectionable ;  it  is  unnecessarily 


Fi-.  2. 


Fi<r.  4. 


long,  its  point  is  apt  to  irritate  the  internal 
wall  of  the  canal,  and  it  is  not  well  adapted  to 
fully  distend  the  meatus. 

"  No.  1,  A"  (Fig.  2),  is  preferable.  The 
abrupt  shoulder  near  the  point  is  well  adapted 
to  fill  the  meatus,  and  the  short  and  rounded 
end  cannot  abrade  the  sensitive  mucous  mem- 
brane. 

Fig.  3  represents  another  excellent  form, 
and  one  which  is  recommended  by  Prof.  Sig- 

Fig.  3. 


mund,  of  Vienna.  I  find  a  figure  of  the  same 
in  the  work  of  Dr.  H.  A.  Hacker,  Die  Blen- 
norrhoen  der  Genitalien,  Erlangen,  1850. 

I  know  of  no  syringe,  however,  equally  con- 
venient to  one  recently  introduced,  and  called 
by  its  inventor^  "The  Peerless  Syringe,"  wliich, 
in  addition  to  a  good  nozzle,  has  the  special 
advantage  that  it  can  be  filled  from  any  bot- 
tle. It  is  made  of  glass,  and  provided  with  a 
soft  rubber  sleeve,  by  means  of  which  it  can 
be  inserted  like  a  cork  in  the  mouth  of  the 
vial.  This  having  been  done,  the  vial  is 
turned  bottom  up,  and  the  syringe  is  filled  by 
simply  withdrawing  tlie  piston.  A  facetious 
patient  has  called  it  the  "  Commercial  Trav- 
eller's Pocket  Companion." 


ActiiiU  size  A'li.  1. 


'   R.  Van  der  Kmde,  Apotlicoary,  323  Bowery,  N.  Y. 


50 


URETHRAL    GONORRHCEA    IN    THE    MALE. 


The  "  urethral  syringe  with  extra  long  pipe"  (Fig.  5)  is,  in  fact,  a 
syringe  united  to  a  catheter,  and  is  adapted  for  injections  of  the  deeper 
portions  of  the  canal.  The  catheter  portion  may  be  bent  to  any  curve 
desired  by  first  oiling  it  and  heating  it  over  a  spirit  lamp  ;  its  form  is  then 
retained  by  dipping  it  in  cold  water. 

Fiff.  5. 


The  solution  of  nitrate  of  silver,  in  the  abortive  treatment  of  gonorrhoea, 
may  be  of  considerable  strength,  when  only  one  injection  will  be  required  ; 
or,  it  may  be  weak,  and  in  that  case  should  be  repeated  at  short  intervals 
until  the  effect  produced  be  deemed  sufficient.  I  much  prefer  the  latter 
course,  especially  with  patients  who  apply  to  me  for  the  first  time,  since  it 
enables  me  to  graduate  the  effect  according  to  the  susceptibility  of  the 
urethra,  which  varies  in  different  persons.  The  following  is  the  formula 
for  the  weak  form  of  injection  : — 

B.     Argenti  Nitratis  gr.  j-iss  .     .     .       0!06— 0109 

Aquse  destillatre  §vj      ....  ISOjOO 
M. 

With  this,  as  with  all  injections  in  gonorrhoea,  it  is  essential  to  success 
that  the  surgeon  should  administer  the  injections  to  his  patients,  or  see,  by 
actual  observation,  that  they  know  how  to  use  them.  Verbal  directions 
cannot  be  relied  upon. 

The  patient  should  be  made  to  pass  his  water  immediately  before  inject- 
ing, or,  better  still,  a  quarter  of  an  hour  before.  We  wish  to  clear  the 
urethra  of  matter,  and  to  have  the  bladder  empty  so  that  the  injection  may 
have  some  time  to  act  before  it  is  Avashed  away  by  another  passage  of  the 
urine,  and  yet  a  short  interval  between  the  last  act  of  micturition  and  the 
injection  is  advisable,  in  order  that  as  much  of  the  urine  as  possible  may 
have  drained  from  the  canal  and  little  be  left  to  decompose  the  nitrate  of 
silver.  The  prepuce  should  now  be  fully  retracted,  and  the  glans  penis 
exposed.  The  latter  should  be  wiped  dry,  so  as  to  afford  a  firm  hold  to 
the  thumb  and  forefinger  of  the  left  hand,  applied  laterally,  not  from  above 
doivntvards,  and  firmly  compressing  it  around  the  })oint  of  the  syringe. 
Call  the  patient's  attention  to  the  fact  that  the  opening  of  the  urethra  is  a 
vertical  slit ;  that  compressing  the  glans  from  above  downwards  makes  this 
opening  gape  while  compression  from  side  to  side  closes  it;  hence  the  im- 
portance of  exercising  the  compression  in  the  latter  way  while  taking  the 
injection.  If  the  pressure  be  properly  made,  not  a  drop  of  the  solution  will 
be  lost,  as  the  piston  of  the  syringe  is  slowly  forced  down  by  the  forefinger 


TREATMENT.  51 

of  the  right  hand  holding  the  instrument,  and  the  whole  contents  will  be 
discharged  into  the  canal.  The  syringe  should  now  be  withdrawn,  and  the 
fluid  still  retained  for  a  few  seconds  by  co.'itinuing  the  compression  of  the 
glans.  When  the  injection  is  allowed  to  escape,  it  will  be  found  to  be  of 
a  milky-white  color.  This  is  due  to  the  partial  decomposition  of  the  con- 
tained salt  by  the  remains  of  the  urine  and  the  muco-pus  in  the  canal.  As 
this  decomposition  has  prevented  the  application  of  the  injection  in  its  full 
strength  to  the  urethral  walls,  a  second  syringeful  should  be  thrown  in,  and 
retained  for  two  or  three  minutes.  During  this  time  a  finger  of  the  dis- 
engaged hand  should  be  run  along  the  under  surface  of  the  penis /row?,  behind 
forwards,  so  as  to  distend  the  portion  of  the  canal  occupied  by  the  injec- 
tion, and  insure  the  thorough  application  of  the  fluid  to  the  whole  mucous 
surface. 

This  description  of  the  method  of  using  the  syringe  is,  in  the  main,  ap- 
plicable to  all  the  injections  which  may  be  required  in  the  course  of  a 
gonorrhoea  :  but  we  are  now  si)eaking  of  the  abortive  treatment,  by  means 
of  weak  injections  of  nitrate  of  silver.  We  will  suppose  that  this  first  in- 
jection has  been  administered  by  the  surgeon,  who,  at  the  same  time,  has 
explained  the  various  steps  of  the  operation  to  the  patient.  The  directions 
with  regard  to  diet,  etc..  that  will  presently  be  mentioned  in  speaking  of 
the  second  stage,  should  now  be  given  ;  the  patient  should  be  ordered  to 
repeat  the  injection  every  three  hours,  and,  for  the  present,  it  is  best  that 
he  should  be  seen  by  the  surgeon  twice  a  day.  It  is  also  well  at  this  time 
to  prescribe  an  active  purge. 

The  first  effect  of  the  caustic  injections  is  manifested  in  a  few  hours  ;  the 
discharge  becomes  copious  and  purulent,  and  considerable  scalding  is  felt 
in  passing  water.  In  the  course  of  twenty-four  to  forty-eight  hours,  how- 
ever, the  discharge  grows  thin  and  watery,  and,  very  likely,  is  tinged  with 
blood.  It  is  now  time  to  stop  the  injection  and  omit  all  medication  for  a 
few  days,  until  we  see  how  much  good  has  been  accomplished.  If  the 
treatment  meets  with  success  the  discharge  will  gradually  diminish,  and 
finally  disappear  in  from  three  to  five  days.  vSometimes,  however,  after 
gi'owing  less,  it  again  increases,  showing  a  tendency  to  relapse.  In  this 
case,  I  usually  advise  weak  injections  of  acetate  of  zinc,  as  recommended 
in  the  third  stage  of  the  disease.  Some  surgeons  prefer  to  resume  the 
caustic  injections  in  the  same  manner  fis  at  first  if,  after  a  week  has  elapsed, 
any  traces  of  the  discharge  remain. 

The  chief  objection  to  this  modification  of  the  abortive  treatment  is,  that 
it  is  necessary  to  leave  the  administration  of  most  of  the  injections  to  the 
patient,  who  may  be  prevented  by  ignorance,  or  the  requirements  of  his 
occupation,  from  using  them  as  thoroughly  or  as  often  as  is  necessary.  If 
we  have  reason  to  fear  this,  we  may  resort  to  a  stronger  solution,  and  inject 
it  once  for  all,  with  our  own  hands,  but  I  have  found  the  effect  decidedly 
less  satisfactory.  It  was  this  method  of  em[)loying  the  abortive  treatment 
that  was  recommended  by  Debeney  of  France,  and  Carmichael  of  Eng- 
land, by  wliom  this  treatment  was  first  introduced  to  the  profession.  The 
same  method   is  also  still  employed  and  highly  recommended  by  many 


52  URETHRAL    GONORRHOEA    IN    THE    MALE. 

surgeons,  and  especially  by  M.  Diday  of  Lyons.  The  strong  injection 
should  not  contain  less  than  ten  grains  (O.C)"))  of  the  nitrate  of  silver  to 
the  ounce  (30.00)  of  distilled  water,  and  more  than  fifteen  grains  are 
objectionable,  unless  with  patients  who  have  been  under  treatment  before, 
and  in  whom  the  urethra  has  been  found  to  be  quite  insensible. 

R.     Argenti  Nitratis  gv.  x-xv      .     .       Oj(35 — IjOO 

Aqii?e  destillatse  ^j 30[00 

M. 

The  mode  of  using  this  injection  is  identical  with  that  already  described. 
Two  small  syringefuls  should  be  thrown  in  ;  the  first  to  clear  the  urethra 
of  urine  and  muco-pus,  the  second  to  exercise  a  curative  effect;  and  the 
surgeon  should  feel  that  the  success  of  the  treatment  depends,  in  a  great 
measure,  on  the  thoroughness  of  its  application.  As  an  additional  precau- 
tion against  the  fluid  extending  further  back  than  is  necessary,  the  patient 
may  compress  the  penis  anteriorly  to  the  scrotum,  while  the  surgeon  is 
administering  the  injection ;  or  the  same  result  may  be  accomplished  by 
making  him  sit  astride  the  arm  of  a  chair,  and  thus  compressing  the  urethra 
in  the  perineum. 

There  is  still  another  mode  of  employing  a  strong  solution  of  nitrate  of 
silver,  by  means  of  an  instrument  introduced  by  Dr.  F.  Campbell  Stewart, 
and  called  by  his  name.  This  instrument  consists  of  a  straight  canula 
inclosing  a  sponge,  which  can  be  made  to  protrude  from  its  extremity. 
This  sponge  is  first  soaked  in  a  solution  of  niti-ate  of  silver,  and  concealed 
within  the  canula.  Tlie  instrument  is  then  introduced  for  about  two  inches 
within  the  urethra,  when  the  canula  is  to  be  partially  withdrawn;  tlie 
sponge  is  thus  exposed  to  the  contact  of  the  urethral  walls,  in  which  posi- 
tion it  is  to  be  allowed  to  remain  for  a  minute  or  two,  and  then  withdrawn 
by  slowly  twisting  it  on  its  long  axis.  By  the  use  of  Dr.  Stewart's  instru- 
ment, the  extent  of  the  application  can  be  limited  at  will,  and  it  is  perhaps 
owing  to  this  fact  that  we  can  employ  with  safety  a  much  stronger  solution 
than  when  using  a  syringe.  I  have  thus  applied  a  solution  of  twenty,  and 
even  thirty  grains  to  the  ounce,  without  exciting  an  undue  amount  of  in- 
flammation, or  other  unpleasant  symptoms.  Care  should  be  taken  that 
the  instrument  be  of  sufficient  size.  Some  of  those  found  in  the  shops  are 
too  small,  not  exceeding  a  No.  7  bougie  in  diameter.  I  have  had  one 
manufactured  for  my  own  use  of  the  size  of  No.  10. 

I  cannot  leave  this  subject  of  the  abortive  treatment  of  gonorrluca,  with- 
out again  expressly  stating  that  I  recommend  it  only  in  the  first  stage  of 
the  disease,  and  not  after  acute  inflammatory  symptoms  have  set  in,  or 
w'hile  the  patient  suffers  from  scalding  in  passing  water.  Taking  the  usual 
run  of  cases  as  met  with  in  practice,  prol)ably  not  more  than  one  out  of 
twenty  is  seen  at  a  sufficiently  early  period  to  admit  of  the  abortive  treat- 
ment. Its  employment  in  the  acute  stage,  as  recommended  by  its  inven- 
tors, is  generally  unsuccessful,  and  dangerous  and  even  fatal  results  have 
been  known  to  ensue.  Prudent  practitioners  have  limited  the  use  of  caustic 
injections  to  the  early  stage  of  gonorrhoea,  except  in  some  instances  in  the 


TREATMENT  OF  THE  ACUTE  STAGE.  53 

decline  of  the  disease ;  but,  in  the  latter  case,  the  mode  of  injecting  must 
be  modified,  so  that  the  fluid  may  reach  the  deeper  portions  of  the  canal. 

Treatment  of  the  Acute  Stage The  proper  regulation  of  the  diet,  exer- 
cise, and  mode  of  life  of  the  patient,  is  of  the  first  importance  in  every  stage 
of  gonorrhoea.  In  the  treatment  of  the  inflammatory  stage,  as  well  as  in 
the  abortive  treatment  of  the  first  stage,  if  the  patient  can  keep  his  bed  for 
a  few  days,  the  battle  is  half  won.  Tlie  advantages  of  absolute  repose  and 
quiet  should  be  placed  prominently  before  him,  and  every  inducement  be 
ofl^ered  to  lead  him  to  avail  himself  of  tliem.  Yet  in  practice,  we  find  that 
very  few  will  submit  to  this  constraint.  It  is  very  well  to  say  that  every 
patient  that  puts  himself  under  the  care  of  a  physician,  should  follow  his 
advice  implicitly  in  all  things ;  but  we  must  take  the  world  as  we  find  it, 
and  the  calls  of  business,  or  the  necessity  of  secrecy,  often  render  the  in- 
sistence upon  such  stringent  rules  impossible.  When  life  is  in  danger,  men 
absorbed  in  business  will  stay  at  home,  but  not  merely  for  an  attack  of 
gonorrhoea.  This,  indeed,  should  not  prevent  our  doing  our  best  to  per- 
suade them,  but  we  shall  succeed  in  but  a  small  minority  of  cases. 

Exercise  of  all  kinds  should  be  avoided  as  much  as  possible,  walking, 
dancing,  riding  on  horseback,  and  standing — in  the  street,  at  the  desk,  at 
a  party — are  all  injurious.  Riding  is  certainly  less  objectionable  than 
walking,  and  yet  a  long  ride,  even  in  a  rail-car,  often  aggravates  a  gonor- 
rhoea or  induces  a  relapse  when  it  is  apparently  cured.  At  home,  and  at 
the  store  or  oflice,  the  recumbent  posture  should  be  maintained  as  much  as 
possible.  It  is  highly  important,  also,  that  the  genital  organs  should  be 
well  supported  by  a  suspensory  bandage.  The  kind  of  bandage  is  imma- 
terial, provided  it  supports  well  and  equably  the  scrotal  organs  and  does 
not  chafe.  ]Many  different  kinds  of  suspensory  bandages  are  on  sale,  but 
the  best  of  all  can  be  made  by  the  patient  at  home.  All  that  is  required 
is  an  old  liandkerchief  or  a  soft  piece  of  muslin  folded  in  the  form  of  a 
fillet,  wliich  is  to  support  the  scrotum  like  a  sling.  A  piece  of  tape  is  tied 
I'ound  the  waist ;  the  ends  of  tlie  fillet  in  front  are  brought  under  and  over 
it  and  held  fast  by  clasp-pins.  Then  the  only  difficulty  likely  to  occur  is 
from  the  sling  slipping  off".  This  is  obviated  by  stitching  a  short  tape  to 
its  centre,  passing  the  same  beneath  the  perina;um  and  between  the  but- 
tocks and  tying  it  behind  to  the  tape  round  the  waist.  While  the  more 
acute  symptoms  continue,  the  diet  should  be  exclusively  farinaceous  ;  and 
meat,  stimulants,  asparagus,  cheese,  coffee,  and  acids  be  forbidden.  The 
perusal  of  all  books  calculated  to  excite  the  passions,  and  the  company  of 
lewd  women,  even  if  no  improprieties  be  committed,  sliould  be  strictly 
interdicted.  The  last-mentioned  caution  is  not  generally  given  without 
good  reasf)n. 

At  the  commencement  of  the  treatment  of  a  case  of  gonorrhoea  in  the 
acute  stage,  it  is  well  to  administer  an  active  purge,  as  five  grains  of  calo- 
mel combined  with  ten  of  jalap,  a  full  dose  of  Epsom  salts,  or  three  or  four 
compound  cathartic  pills  of  the  U.  S.  P.  Care  slioidd  Ije  taken  to  keep 
tlie  head  of  the  penis  ^nm  from  any  collection  of  matter,  lest  balanitis  be 
excited  or  the  disease  be  aggravated  by  its  presence.     A  i)airof  triangular- 


54  URETHRAL    GONORRHCEA    IN    THE    MALE. 

shaped  tlmwers,  like  ordinary  swimming  drawers,  worn  next  the  skin, 
affords  the  best  protection  to  the  patient's  linen.  Water,  as  hot  as  can  be 
borne,  is  the  most  grateful  local  application  that  can  be  used.  I  have  found 
that  it  generally  affords  great  relief  to  the  scalding  in  micturition  and  the 
local  pain  and  uneasiness,  and  can  fully  indorse  Mr.  Milton's  statement 
■with  regard  to  it.  "  The  only  direct  application  which  I  can  safely  say 
has  never  disappointed  me,  wiiich  is  at  once  safe,  simple,  and  useful,  is 
that  of  very  hot  water  to  tlie  penis.  But  to  obtain  the  really  good  effects 
it  offers,  the  water  must  be  hot,  not  lukewarm.  In  fact,  we  seldom  see  so 
much  good  ensue  as  when  it  is  carried  to  the  extent  of  producing  some  ex- 
coriation and  faintness  ;  thus  applied,  and  especially  in  the  early  stages  of 
the  disease,  the  weight  felt  about  the  testicles  soon  disappears,  the  pain  on 
making  water  and  using  injections  is  soothed,  and  the  prepuce  and  glans 
rapidly  regain  a  more  normal  temperature  and  color."^  The  best  method 
of  employing  it  iS  to  direct  the  patient  to  immerse  his  penis  in  a  cqp  of 
hot  water  for  a  few  minutes  before  and  after  using  the  injection. 

After  the  operation  of  the  cathartic,  we  may,  in  most  cases,  commence 
at  once  witli  copaiba  or  cubebs,  rules  for  the  exhibition  of  which  will  pres- 
ently be  given  at  length.  If,  however,  the  penis  be  still  much  swollen, 
and  the  scalding  on  passing  water  severe,  we  may  defer  the  exhibition  of 
the  anti-blenorrhagics  for  a  few  days,  and  administer  alkalies  or  diuretics, 
either  alone  or  combined  with  sedatives,  for  the  purpose  of  rendering  the 
urine  less  irritating  by  diminishing  its  acidity,  or  diluting  its  contained 
salts  by  increasing  its  quantity.  Again,  both  these  classes  of  remedies 
may  be  given  at  the  same  time.  From  one  to  two  drachms  of  the  chlo- 
rate, acetate,  or  nitrate  of  potash,  or  two  or  three  drachms  of  li<iuor  potas- 
Sdn,  may  be  added  to  a  pint  of  flaxseed  tea  ;  and  the  patient  be  directed  to 
take  this  quantity  in  the  course  of  twenty-four  liours.  The  following  is 
also  an  excellent  formula  : — 

R.     Potassse  Bicarbonatis  ^i 30  00 

Tincturjft  Hyoscyami  §j 30,00 

Mucilaginis"§vi] 250100 

M. 
A  teaspoonfiil  (15.00)  every  four  hours. 

Tincture  of  hyoscyamus  and  liquor  potassa?  are  often  given  in  the  same 
prescription.  Chemists  say  that  this  is  a  combination  of  incompatibles, 
and  that  the  effect  of  the  former  is  destroyed  by  a  caustic  alkali.^  In  prac- 
tice, however,  it  is  pretty  generally  admitted  that  this  objection  does  not 
obtain.  In  this  stage  of  the  disease,  Mr.  Milton  highly  recommends  tlfe 
following  : — 


1  Milton  on  Gonorrlinea,  p.  21. 

2  See  Paris's  Pharmacologia,  Ninth  Edition,  p.  512.  This  fact  has  been  brought 
forward  as  new,  and  confirmed  by  actual  experiment,  by  Dr.  Ctarrow,  Medico- 
Chirurgioal  Transactions,  Second  Series,  vol.  xxiii,  London,  1858. 


TREATMENT  OP  THE  ACUTE  STAGE.  55 


R.     Pulv.  Potassse  Chloratis  5ij 

.     8;oo 

Aqiise  buUientis  .^v     . 

.  150  00 

Misce  et  adde — 

Liquoris  Potassfe  5iij       •     • 

.     12  00 

Potassse  Acetatis  5iij  ficl  3"^ 

.     12  00—20100 

Misce  et  cola. 

One  ounce  three  times  a  day. 

If  the  bowels  be  not  freely  open,  ]Mr.  Milton  adds  powdered  rhubarb  to 
each  dose  of  this  mixture,  in  sufficient  quantity  (gr.  v  ad  9j)  to  produce 
two  or  three  loose  stools  daily.  The  following  is  another  formula  recom- 
mended by  Mr.  Milton  : — 

R.     Potassae  Acetatis  5)       .......     30[ 

Spirit,  ^theris  Nitrici  5iij 12| 

Aquse  Campliorse  §vj 200 1 

M. 

One  ounce  three  times  a  day. 

Fournier's  favorite  formula  is  — 

R.     Sod;e  Bicarb,  gr.  xlv-lxxv     .     .       3|         5 

Sacch.  albi  5x 40 

Spiritus  Limonis  gtt.  j-ij  .     .     .       0:06—0  12 
Dissolve  in  a  pint  or  a  pint  and  a  half  of  cold  water,  and  this  quantity  to  be 
taken  daily  between  meals. 

An  elegant  and  convenient  method  of  administering  an  alkali  is  by 
means  of  Dunton's  or  Wyeth's  compressed  pills  of  bicarbonate  of  potassa, 
of  which  two  or  more  may  be  given  after  each  meal. 

Digitalis  was  recommended  by  Beranger-Ferand^  in  the  early  stages  of 
gonorrhoea,  as  quieting  painful  erections  and  exercising  a  marked  influence 
in  the  cure  of  the  disease.  Zeissl  made  a  trial  of  it,  giving  from  twelve 
to  eighteen  drops  of  the  tincture  four  times  a  day,  and,  in  several  cases, 
found  marked  benefit.  In  other  cases  of  acute  gonorrhcea,  it  seemed  to 
produce  hyperaimia  of  the  neck  of  the  bladder,  as  shown  by  frequent  desire 
to  urinate,  blood  mixed  with  the  last  drops  of  urine,  etc.  He  found  that 
tlie  more  rapidly  the  pulse  was  reduced  to  forty-eight  or  fifty  per  minute, 
the  better  the  effect  en  the  discharge.  In  any  trial  of  this  drug,  care 
should  of  course  be  taken  that  it  is  not  carried  to  a  dangerous  extent.  Jar- 
nowski  says  the  inf.  digitalis  is  his  favorite  prescription  when  the  dis- 
charge has  become  purulent  and  pain  is  felt  in  passing  water  and  in  erec- 
tions. 

If  the  penis  be  much  sw^ollen  and  florid,  the  meatus  contracted  by  the 
distention  of  its  walls,  and  the  urethra  very  sensitive,  the  above  general 
measures  should  constitute  the  only  treatment,  and  no  local  remedies,  with 
the  exception  of  hot  water,  be  resorted  to,  until  the  inflammation  has  some- 
what subsided.  In  the  majority  of  cases,  however,  especially  when  the 
patient  lias  had  gonorrhoea  before,  the  local  symjjtoms  are  not  severe,  even 
in  the  acute  stage,  and  the  jmint  of  a  syringe  can  be  gently  introducetl 

'  Etude  sur  Paction  antiblcnnorrhagique  de  la  digitale,  Bull.  g(;n.  de  thdrap. 
Ixxiii,  1867,  p.  202. 


56  URETHRAL    GONORRIICEA    IN    THE    MALE. 

within  the  canal  without  exciting  much  pain.  When  this  is  the  case,  an 
injection  containing  glycerine  and  strongly  opiated,  will  be  found  to  afford 
relief  to  the  local  pain  and  uneasiness,  and  hasten  the  subsidence  of  the 
inflammatory  symptoms,  and  the  diminution  of  the  discharge.  I  can  speak 
very  decidedly  in  favor  of  this  application  and  of  its  perfect  safety ;  but 
the  opium  must  not  be  added  in  the  form  of  tincture,  or  the  alcohol,  which 
is  an  irritant,  w^ill  counteract  its  effect;  and  the  fluid  is  to  be  injected  with 
gentleness,  and  not  with  such  force  as  to  painfully  distend  the  canal.  The 
foUowin";  is  the  formula  that  I  use : — 


I^.     Extracti  Opii  9j 1 

Glycerinre  §j 38 

Aqufe  §iij 90 

M. 
Injection  to  be  used  after  every  jjassage  of  urine. 


In  many  cases  of  a  subacute  form,  half  a  grain  or  a  grain  of  acetate  or 
sulphate  of  zinc  may  be  added  to  each  ounce  of  the  mixture,  even  at  the 
outset,  and  there  are  but  few  cases  in  which  it  is  not  admissible  in  the 
course  of  a  few  days,  whenever  the  inflammation,  local  pain,  and  scalding 
are  found  to  be  much  improved.  Half  a  drachm  of  Goulard's  extract  to 
four  ounces  of  water,  is  also  an  excellent  injection  as  the  inflammatory 
symptoms  begin  to  subside.  If  the  case  continue  to  progress  favorably, 
the  quantity  of  the  astringent  may  be  gradually  increased,  and  that  of  the 
opiate  diminished  ;  and  the  treatment  should  be  continued  according  to  the 
rules  laid  down  for  the  third  stage,  to  be  mentioned  presently. 

While  pursuing  the  treatment  of  the  acute  stage  of  gonorrhoea,  care 
should  be  taken  that  antiplilogistic  measures  be  not  too  long  persevered 
Avith.  It  should  be  remembered  that  the  natural  tendency  of  the  disease 
is  to  lower  the  tone  of  the  system,  and  a  condition  of  debility  in  turn  reacts 
on  the  disease  and  prolongs  its  duration.  We  often  meet  with  patients 
wdio  have  treated  themselves  with  low  diet  and  daily  purging  for  weeks, 
and  yet  who  are  no  better  of  their  gonorrhoea.  An  antiphlogistic  course 
alone  may  relieve  the  more  acute  symptoms,  but  it  will  not  cure  the  com- 
plaint ;  and  so  soon  as  the  pain  in  passing  water  has  diminished  and  the 
local  inflammation  in  a  measure  subsided,  the  })atient  should  no  longer  be 
conflned  to  his  room,  and  should  have  a  more  liberal  diet;  nor,  under  any 
circumstances,  should  his  confinement  and  abstinence  be  prolonged,  if  after 
a  reasonable  time,  they  are  found  to  produce  no  change  for  the  better,  or 
the  pulse  becomes  feeble,  the  skin  clammy,  and  the  strength  exhausted. 
Indeed,  in  some  cases,  in  which  the  constitution  is  enfeebled  by  disease, 
debauch,  or  previous  attacks  of  venereal,  it  is  necessary  to  abstain  from  all 
measures  calculated  to  lower  the  tone  of  the  system,  and  resort  to  good 
living  and  even  quinine,  iron,  and  other  tonics,  from  the  very  outset. 

Treatment  of  the  Starje  of  Decline A  marked  diminution  of  the  scald- 
ing in  making  water,  and  of  the  painful  sensations  in  the  penis,  is,  I  believe, 
a  better  index  of  the  subsidence  of  the  inflammatory  action,  than  the  char- 
acter of  the  discharge,  which,  independently  of  treatment,  often  continues 
copious  and  purulent  after  the  third  stage  has  fairly  commenced. 


TREATMENT    OF    THE    STAGE    OF    DECLINE.  51 

In  giving  directions  as  to  the  regimen  of  a  patient  in  the  third  stage  of 
gonorrhoea,  some  regard  should  he  paid  to  his  usual  mode  of  life.  As  a 
general  rule,  all  indulgence  in  spirituous  or  malt  liquors  should  be  strictly 
forbidden,  and  total  abstinence  be  practised  until  the  cure  is  complete,  and 
for  at  least  a  fortniglit  afterward.  You  will  meet  with  some  patients,  how- 
ever, who  have  been  free  drinkers  for  years,  and  who  will  not  well  bear 
the  total  loss  of  their  stimulus,  without  becoming  so  debilitated  that  their 
gonorrhoea  is  thereby  prolonged  and  more  difficult  to  cure.  In  these  ex- 
ceptional  cases,  it  is  better  to  allow  a  glass  of  claret,  sherry,  or  even 
brandy  and  water,  to  be  taken  with  the  dinner.  In  any  case,  malt  liquors 
and  champagne  should  be  avoided,  since  they  are  decidedly  more  injurious 
tlian  other  liquors  which  contain  a  larger  amount  of  alcohol.  The  patient 
may  now  return  to  a  more  generous  but  simple  diet,  though  salt  meats, 
liighly  seasoned  food,  asparagus,  and  cheese  should  still  be  avoided.  The 
bowels  are  not  to  be  allowed  to  become  constipated,  and  this  should  be 
prevented  so  far  as  possible  by  regulating  the  diet.  One  or  two  free  stools 
a  day  are  desirable.  If  the  patient  have  been  confined  to  the  house  during 
the  acute  stage,  he  may  now  be  allowed  to  go  out,  but  should  be  cautioned 
against  walking  or  standing  more  than  is  necessary,  and  the  genital  organs 
should  be  well  supported  by  a  suspensory  bandage.  Patients  often  in- 
quire whether  the  use  of  tobacco  is  injurious;  I  believe  that  it  is,  and  that 
either  smoking  or  chewing,  especially  in  excess,  weakens  the  genital 
organs  and  tends  to  keep  up  a  urethral  discharge.  I  have  frequently  been 
told  by  patients  subject  to  spermatorrhoea,  that  smoking  during  the  even- 
ing would  invariably  be  followed  by  an  emission  during  the  night,  and  I 
am  satisfied  that  many  cases  of  gonorrhoea  are  prolonged  by  the  excessive 
use  of  tobacco.  I  therefore  recommend  entire  abstinence,  or,  at  least, 
great  moderation,  both  in  smoking  and  chewing,  to  persons  suffering  with 
this  disease.^ 

The  clnef  remedies  adapted  to  the  third  stage  of  gonorrhoea  are  injec- 
tions, and  copaiba  and  cubebs.  By  far  the  more  important  of  these  are 
injections,  wliieli  constitute  our  chief  reliance  in  tlie  treatment  of  this 
atfection,  when  it  has  arrived  at  tliis  stage ;  and,  in  spite  of  all  that  has 
been  written  and  said  against  them,  I  do  not  hesitate  to  say,  that  the 
surgeon  who  voluntarily  renounces  injections  deprives  himself  of  his  best 
w(*a})on  in  contending  with  gonorrhtea,  and  is  conqjaratively  impotejit  in 
his  attempts  to  conquer  it. 

The  objections  that  have  been  raised  against  this  mode  of  treatment 
need  not  long  detain  us.  They  are  chiefiy  the  following  :  1.  It  is  asserted 
that  the  injected  fluid  carries  before  it  the  muco-pus  within  the  urethra, 
and  thus  extends  the  disease  to  the  deeper  portions  of  the  canal.  Suppos- 
ing this  possible  in  any  case,  it  cannot  take  jjlace  if  the  patient  pass  his 
water  before  injecting,  as  he  should  always  be  directed  to   do.      2.   It  is 

'  Dr.  Shipley  has  published  two  cases  of  gonorrhoea  in  which  Iho  discharge  re- 
peatf'dly  disappearcnl  on  h-aving  ofF  smoking,  and  returned  on  resuming  it.  {Boston 
Med.  and  Sanj.  Joiinud,  Nov.  22,  18GU.) 


58  URETHRAL  GONORRH(EA  IN  THE  MALE. 

said  that  injections  may  excite  swelled  testicle  and  other  complications  of 
gonorrhoea.  This  is  only  possible,  when  they  are  used  of  too  great  strength 
or  with  undue  violence.  3.  It  is  supposed  by  some  persons  that  there  is 
danger  of  the  injection  penetrating  the  bladder.  I  formerly  supposed  that 
this  was  impossible  with  a  syringe  merely  penetrating  a  short  distance 
Avithin  the  meatus,  but,  although  I  have  since  been  convinced  of  my  error 
by  the  fact  that  patients  of  mine  suffering  from  cystitis  have  been  able  to 
wash  out  the  bladder  Avith  an  ordinary  Davidson's  syringe,  its  point  only 
introduced  within  the  meatus,  yet  this  result  can  only  be  attained  by  prac- 
tice, and  is  not  at  all  likely  to  occur  in  the  ordinary  mode  of  using  urethral 
syringes.  Moreover,  no  harm  would  ensue  even  if  a  portion  of  the  fluid 
should  enter  this  viscus,  for  it  would  be  immediately  neutralized  by  the 
urine.  4.  The  chief  objection  that  has  been  alleged  against  injections  is 
that  they  are  a  frequent  cause  of  stricture  of  the  urethra.  This  the  oppo- 
nents of  injections  have  endeavored  to  prove,  by  showing  that  most  per- 
sons with  stricture  preceded  by  gonorrhosa  were  treated  for  the  latter 
disease  by  injections.  This  is  clearly  a  mode  of  reasoning,  post  hoc  ergo 
propter  hoc,  and  by  no  means  proves  the  ground  assumed.  I  have  heard 
of  some  one,  who,  to  show  its  fidlacy,  instituted  some  inquiries  among 
patients  with  stricture,  as  to  Avhether  they  had  taken  flaxseed  tea  for  their 
previous  gonorrhoea,  and  who  was  able  to  prove,  if  such  reasd*ning  be  reli- 
able, that  flaxseed  tea  is  a  very  fruitful  source  of  stricture.^  As  Ricord 
justly  states,  it  is  much  more  probable  that  strictures  are  due  to  the  chronic 
inflammation,  which,  in  cases  of  gonorrhocal  origin,  has  usually  preceded 
them  for  a  long  period,  than  to  any  influence  exercised  by  injections.  This 
well-known  effect  of  chronic  inflammation  of  a  mucous  membrane  in  pro- 
ducing- an  effusion  of  plastic  material  in  the  submucous  cellular  tissue, 
which  by  its  contraction  diminishes  the  calibre  of  the  canal,  is  a  strong 
argument  in  favor  of  this  view.  The  objections  to  the  use  of  injections 
are,  I  believe,  founded  on  their  abuse,  on  false  reasoning,  or  on  prejudice, 
and  will  not  stand  the  test  of  examination.  When  properly  used,  these 
are  the  most  valuable  means  within  our  reach  for  the  cure  of  gonorrhoea, 
and  are  em[)loyed  in  the  practice  of  all  surgeons,  with  very  few  exceptions, 
who  have  had  the  opportunity  of  testing  their  value. 

Injections  are  particularly  adapted  to  the  treatment  of  the  first  stage  by 
the  abortive  method  and  to  the  treatment  of  the  third  stage  of  gonorrhoea  ; 
although,  as  already  stated,  in  very  many  cases  they  may  be  used  with 
safety  and  benefit  in  a  weak  form,  even  in  the  second  or  acute  stage. 

These  remarks  in  favor  of  injections  do  not  of  course  im})ly  that  they 
are  infallibly  successful,  nor  that  they  can  be  used  indiscriminately  in  all 
cases.  Under  certain  circumstances,  their  effect  is  found  to  be  injurious. 
If  in  the  course  of  treatment  the  patient  complain  of  a  frequent  desire  to 

'  An  amusing  instance  of  misconstruing  the  English  language  is  given  by  M. 
JuUien,  who  quotes  the  author  of  this  work  as  here  stating  that  "  strictures  follmv- 
imj  (jonorrkcca  have  no  other  orifjin  than  the  immoderate  use  of  tea  //"  (Jullieu,  Mai.  ven. 
p.  55.) 


TREATMENT    OF    THE    STAGE    OF    DECLINE.  59 

pass  his  urine,  and  other  symptoms  indicating  irritation  or  inflammation  of 
the  neck  of  the  bladder  or  prostate,  injections  should  be  at  once  suspended. 
Continuous  pain  in  the  penis,  or  any  considerable  amount  of  tumefaction 
of  its  tissues  also  contra-indicates  the  use  of  irritant  or  astringent  injec- 
tions. 

Moreover,  it  should  not  be  forgotten  that  injections  will  sometimes  keep 
up  a  discharge  through  the  irritation  which  tliey  excite,  however  simple 
may  be  their  composition.  After  the  force  of  the  disease  has  been  subdued, 
they  should  therefore  be  used  at  gradually  increasing  intervals,  or,  from 
time  to  time,  be  altogether  omitted,  until  the  necessity  of  their  continuance 
again  becomes  apparent. 

The  manner  of  using  the  syringe  in  the  third  stage  is  essentially  the 
same  as  in  the  abortive  treatment  of  the  first  stage.  A  larger  syringe, 
however,  should  be  employed,  one,  for  instance,  liolding  three  or  four 
draclims  ;  since  there  is  now  no  necessity  of  limiting  the  action  of  the 
injection  posteriorly,  and,  on  the  contrary,  it  is  desirable  to  extend  it  as 
far  back  as  possible,  in  order  that  it  may  reach  the  whole  diseased  surface. 
For  this  purpose  the  finger  may  be  run  along  the  under  surface  of  the 
urethra  from  before  backwards,  as  well  as  in  the  opposite  direction  (from 
behind  forwards),  as  previously  recommended,  in  order  to  insure  complete 
distention  of  the  canal  and  exposure  of  its  lacunar.  The  patient  should 
always  pass  his  water  before  injecting,  and  throw  in  two  syringefuls  at 
each  application. 

A  great  variety  of  substances  have  been  recommended  as  the  active 
principles  of  injections.  A  choice,  to  a  certain  extent,  is  doubtless  desirable, 
since  the  same  injection  does  not  always  succeed  equally  well  in  all  cases. 
For  instance,  one  of  my  patients,  whom  I  have  repeatedly  treated  for 
gonorrhoea,  is  always  made  worse  by  an  injection  of  sulpliate  of  zinc,  and 
is  benefited  by  a  weak  solution  of  nitrate  of  silver.  Peculiarities  of  this 
kind  are  occasionally  met  witli,  but  I  believe  that  much  time  is  wasted  by 
young  practitioners  in  changing  from  one  to  another  of  the  many  varieties 
of  injections  proposed  in  books,  under  the  supposition  that  some  specific 
effect  is  to  be  obtained  from  tlie  contained  ingredients,  whereas,  in  most 
cases,  success  depends  upon  the  thoroughness  of  the  application,  and  atten- 
tion to  the  general  health  and  any  existing  complications. 

My  own  preferences  for  an  astringent  in  the  third  stage  of  gonorrhoea 
are  very  strongly  in  favor  of  the  acetate  of  zinc,  which  is  also  the  favorite 
injection  of  Sigmund  of  Vienna,  ^Ir.  Milton,  and  many  other  eminent 
surgeons.  I  have  already  spoken  of  the  addition  of  a  small  quantity  of 
tliis  salt  to  the  sedative  injections  of  tlie  acute  stage,  after  the  more  in- 
fl^immatory  symptoms  have  been  subdued.  The  proportion  of  the  acetate 
may  be  increased  and  that  of  the  opiate  diminished,  as  the  case  progresses, 
and  the  latter  finally  be  omitted  altogetlier.  The  strength  of  the  injection 
should  be  such  that  it  may  excite  a  slight  uneasy  sensation  in  the  urethra 
for  five  or  ten  minutes,  but  it  must  not  be  strong  enough  to  cause  severe 
or  long-continued  pain.  As  the  case  a[)proaclies  a  cure,  the  injection  will 
cease  to  excite  any  unpleasant  feeling  whatever,  and  its  strength  need  not 


GO  URETHRAL    GONORRHOEA    IX    THE    MALE. 

be  further  increased.     In  most  cases,  Ave  need  not  at  any  period  exceed 
tlie  proportion  of  the  acetate  in  the  following  formula: — 

5.     Zinci  Acotatis  gr.  xij ISO 

Aqure  §iv 120| 

M. 

Glycerine  may  be  substituted  for  half  an  ounce  or  an  ounce  of  the 
water.  As  to  the  frequency  with  whicli  the  injection  is  to  be  used,  I 
usually  direct  the  patient  to  inject  after  each  passage  of  his  urine,  with  the 
expectation  that  he  will  take  four  or  five  injections  in  the  course  of  the 
twenty-four  hours. 

If  the  discharge  do  not  materially  diminish  under  the  use  of  these  injec- 
tions, either  alone  or  combined  with  the  internal  administration  of  copaiba 
or  cubebs,  I  usually  resort  to  a  solution  of  nitrate  of  silver,  of  the  strength 
of  from  two  to  five  grains  to  the  ounce  of  water,  and  inject  it  myself  for 
the  patient,  daily,  or  every  two  or  three  days,  while  at  the  same  time  he  is 
directed  to  continue  his  injection  of  sulphate  of  zinc.  The  effect  of  an 
irritant  like  nitrate  of  silver  should  be  closely  watched,  and  its  administration 
should  not,  therefore,  be  left  to  the  patient  himself. 

The  sulphate  of  zinc  is  nearly,  though  not  quite,  as  valuable  a  remedy  as 
the  acetate,  and  the  remarks  above  made  in  favor  of  the  latter  are  in  a 
measure  applicable  to  the  former.  Indeed,  if  I  were  asked  to  name  the 
simplest  treatment  of  gonorrhoia,  and  the  one  best  adapted  to  the  largest 
number  of  cases,  I  should  reply  :  a  weak  injection  of  the  sulphate  or  ace- 
tate of  zinc,  containing  from  one  to  three  grains  to  the  ounce  of  water. 
Many  men  about  town  constantly  carry  in  their  pockets  a  prescription  of 
this  kind  (generally  Avith  the  addition  of  a  little  morphine  or  a  fiew  grains 
of  powdered  opium),  with  which  they  sometimes  succeed  in  arresting  their 
frequent  attacks  of  gonorrhcca,  without  resorting  to  the  nauseous  anti- 
blennorrhagics,  or  finding  it  necessary  to  consult  a  surgeon. 

The  sulphate  of  zinc  was  a  favorite  with  Dr.  Graves,  who  was  in  the 
habit  of  combining  it  with  the  impure  cai'bonate  of  zinc,  as  in  the  follow- 
ing formula  : — 

R.     Zinci  Sulphatis  gr.  iij 0:20 

Calamiine  gr.  x 0  (55 

Mucilaginis  5ij 10,00 

Aquff  §vj 180|00 

M. 

With  regard  to  the  addition  of  calamine,  Dr.  Graves  says  :  "  How  the 
lapis  calaminaris  acts,  unless  on  a  mechanical  principle,  it  is  difficult  to 
explain ;  but  of  its  utility  I  am  certain,  having  long  used  this  combina- 
tion, as  recommended  in  Thomas's  Practice  of  Physic."^ 

The  chloride  of  zinc  is  a  powerful  caustic  and  irritant  which  fulfils,  al- 
though in  a  much  less  perfect  manner,  the  same  indications  as  nitrate  of 
silver,  and  may,  therefore,  be  used  under  similar  circumstances. 

The  sulpho-carbolate  of  zinc   has   been   employed  in   about  the    same 

'  Clinical  Lectures,  London  Med.  Gaz.,  new  series,  vol.  i.,  1838-9,  p.  438. 


TREATMENT    OF    THE    STAGE    OF    DECLINE.  61 

Strength  as  the  sulphate,  but  possesses  no  advantage  over  the  latter,  so  far 
as  I  know. 

Of  the  numerous  other  formula?  for  injections  sometimes  employed  in 
the  treatment  of  gonorrlia^a,  the  follo\ving  are  among  the  best  : — 

I^.     Cupri  Sulphatis  gr.  xij     .     .  O'SO 

Aquje  5iv-vj 125  00—185  00 

M. 

I^.     Liq.  Plumbi Subacetatis §ss-j  16100—  32100 

Aqu.-egiv-vj 125|00— 18500 

M. 

f^.     Aluminis  gr.  xij-xxx  .     .     .  0^80 —     2i00 

Aqiue  §iv        125 1 

M. 

Mr.  Milton  says  of  alum  :  "  The  absence  of  pain  which  follows  its  use, 
and  its  feeble  curative  power,  have  led  me  to  assign  to  it  only  a  secondary 
rank.  I  am,  indeed,  extremely  doubtful,  if  it  possesses  any  superiority 
over  very  mild  injections  of  nitrate  of  silver  or  sulphate  of  zinc,  and 
would,  therefore,  confine  its  exhibition  to  those  cases  accompanied  by 
severe  pain,  where  it  may,  during  a  day  or  two,  serve  as  a  pioneer  to  the 
others." 

In  the  following  we  have  a  combination  of  alum  and  sulphate  of  zinc  : — 

R.     Liq.  Aluminis  Comp.  5J 30100 

Aqufe  giij  .     .     .     .     ". 90|00 

M. 

The  two  following  are  excellent  formulae,  much  employed  by  Ricord  : — 

IJ.     Ziiici  Sulphatis, 

Plumbi  Acetatis,  aa  gr.  xxx      .     .     .         2100 
AquK  Ros:e  §vj ISOJOO 

M. 

R.     Zinci  Sulphatis  gr.  xv IjOO 

Plumbi  Acetatis  gr.  xxx       ....  2  00 
Tiucturffl  Catechu, 

Viui  Opii,  aa  3J 4  00 

Aquie  Kosc-e  §vj 180  00 

M. 

The  "  Injection  Bru,"  a  French  proprietary  article,  which  is  much  used 
by  "  men  about  town,"  is  said  by  llager  to  be  made  according  to  this  last 
formula.  The  two,  however,  do  not  correspond  in  tlieir  color  or  in  the 
amount  of  .sediment  in  the  bottle.  That  the  injection  Bru  contains  both 
sulphate  of  zinc  and  acetate  of  lead  is  evident  on  chemical  analysis.  I 
have  suspected  that  krameria  was  the  vegetable  astringent  in  tlie  mixture, 
whicli  may  be  closely  imitated  by  using  the  following  formula  : — 

IJ.     Ziuci  Siilph.  gr.  xv 1| 

I'lunibi  Acctat.  gr.  xxx 2 

l"]xt.  Krameriffi  H.,  I 

Tr.  Opii,  aii  3iij 12 

Aquani  ad  §vj 18(1, 

M. 


62  URETHRAL    GONORRIKEA    IN    THE    MALE. 

Vegetable  astringents  may  be  employed  either  alone  or  in  combination 
with  the  salts  of  the  metals,  but  are  in  general  inferior  to  the  latter. 

R.     Vini  Rubri  §vj 180100 

Afidi  Taiinici  gr.  xviij l|20 

M. 

K.     Zinci  Sulphatis, 

Acidi  Taniiici,  aa  gr,  xij 0180 

AtiUffi  §iv 120|00 

M. 
Tannate  of  zinc  is  formed  by  decomposition  of  the  sulphate. 

H.     PotassK  Permanganatis  gr.  xxxvj      .         2135 

Aqu.-B  ^vj ISOjOO 

M. 

(Dr.  John  G.  Rich,  of  Canada.) 

The  formula  for  the  "  Matico  (?)  injection,"  as  commonly  sold  by  that 
name,  is  as  follows  : — 


R.     Zinci  Acetatis  gr.  vj    . 
Morphine  Acetatis  gr.  j 
Acidi  Tannic!  gr.  iij     . 
Aq.  Flor.  Aurantii  5j 
Aquse,  q.  s.  ad  §j    .     . 


30  00 


M. 


Injections  of  tincture  of  aloes  are  recommended  by  Gamberini,^  of 
Bologna,  who  states  that  they  excite  only  a  momentary  smarting  sensa- 
tion, and  are  very  efficacious. 

R.     Tinct.  AloiJs  §ss 15100 

Aquc-e  §iv 120|00 

M. 

The  subnitrate  of  bismuth  is  an  excellent  injection.  It  acts  as  a  local 
sedative,  and,  deposited  upon  the  walls  of  the  urethra,  serves  to  protect  the 
diseased  surfaces  from  contact.  Of  52  patients  treated  exclusively  with 
injections  of  subnitrate  of  bismuth,  3(3  recovered  after  an  average  treat- 
ment of  twenty-two  days.^  I  have  found  only  one  difficulty  attending  its 
use,  viz.,  that  it  clogged  up  the  urethra,  and  by  its  mechanical  presence 
excited  an  uneasy  sensation,  which  was  only  relieved  by  the  passage  ot 
the  urine.  As  it  is  not  soluble  in  water,  it  should  be  suspended  by  means 
of  common  mucilage,  or  better  still  (on  account  of  the  liability  of  the 
former  to  become  rancid)  mucilage  of  sassafras  or  quince  seeds,  or  glyce- 
rine, and  the  bottle  be  shaken  before  using. 

R.     Bismuthi  Subnitratis  3j        ....  4;00 

Mucilaginis  Cydonii  §ss 20,00 

Aqua'  §vss IGSJOO 

M. 

Injections  of  clay-earth,  as  recommended  bylTewson''  and  Godon,*must 
act  chiefly  in  the  same  way  as  bismuth,  by  separating  the  urethral  walls, 

'  Rev.  de  th^rap.  mM.-chir.,  Paris,  Jan.  1,  18(50,  p.  13. 

2  ViCTOii  DE  Meric  :  Report  to  the  Medical  Society  of  Loudon,  April  30,  18G0. 

3  Repts.  Pemi.  Hosp.,  vol.  ii,  18G9. 

*  Am.  J.  Syph.  &  Derm.,  N.  Y.,  1874,  p.  337. 


COPAIBA    AND    CUBEBS  63 

and  are  open  to  the  same  objection,  that  of  clogging  the  canal,  unless 
sufficiently  diluted. 

Dr.  Irwin  (U.  S.  Army)  relies  upon  an  injection  of  chlorate  of  potassa 
(5j  a,d  aquiB  fviij),  repeated  every  hour  for  the  tirst  twelve  hours,  and 
gradually  decreasing  the  frequency  until  the  second  or  third  day,  when  he 
states,  "the  disease  will  be  generally  found  to  have  ceased." (?) 

Mr.  G.  Borlase  Childs  employs  an  injection  of  the  liquor  hydrargyri 
nitratis  (ni^ss  ad  aquas  |j),  repeated  three  times  a  day. 

Western  eclectics,  so  called,  often  use  hydrastin,  either  alone  or  combined 
with  leptandrin. 


R.     Hydrastin  gr.  x 0 

Leptandrin  gr.  iv 0 

Ac^uje  §iv 120 

M. 


Prof.  Bartholow,  in  his  excellent  "  Treatise  on  Materia  Medica",  says 
he  has  seen  no  injection  so  frequently  successful  in  gonorrhoea  as — 

R.     Hydrastift"  3i 4}00 

Mucilag.  Aeaciai  giv 150[00 

M. 

"  Or  the  fluid  extract,  diluted  to  one-half  or  three-fourths  with  water, 
may  be  used  for  the  same  purpose."  I  often  prescribe  a  solution  of  the 
muriate  of  hydrastin,  about  one-half  grain  (U.03)  to  the  ounce  (30.00),  with 
very  good  result. 

Soluble  bougies,  so  called  "  Reynal's  medicated  bougies,"  containing 
various  astringents  combined  or  not  with  sedatives,  and  intended  to  be  in- 
troduced into  the  urethra  and  allowed  to  remain  there  till  they  dissolve, 
though  ingenious,  have  not  proved  of  any  special  value. 

Finally,  in  many  cases  of  gonoi-rhcea,  simple  iced-Avater,  injected  after 
each  passage  of  the  urine,  is  very  serviceable  in  allaying  pain  and  irritation, 
and  not  inefficacious  for  the  cure  of  the  discharge. 

Copaiba  and  Cubebs Certain  drugs  which  appear  to  possess  a  peculiar 

power  in  arresting  inflammation  of  the  urethral  mucous  membrane,  are 
called  anti-blennorrhagics.  The  chief  of  them  are  copaiba  and  cubebs. 
Some  interesting  investigations  made  by  Ricord  to  determine  the  mode  of 
action  of  these  agents,  are  given  in  Ricord  and  Hunter  on  Venereal.  It 
had  already  been  observed  in  practice  that  copaiba  and  cubebs  had  but 
little  curative  effect  upon  gonorrha;a  of  any  portion  of  the  male  or  female 
genital  organs,  except  the  urethra  ;  and  it  was  hence  suspected  that  they 
acted  chiefly  by  their  presence  in  the  urine,  and  not  through  the  general 
circulation  ;  but  this  fact  had  not  been  demonstrated.  A  man  with  gonor- 
rhcx;a  chanced  to  enter  Ricord's  ward  at  the  Hopital  da  Midi,  who  had  a 
fistulous  opening  communicating  with  the  urethra  a  short  distance  in  front 
of  the  scrotum,  produced  by  a  ligature  which  had  been  applied  around  his 
j)enis  when  a  child.  He  could  at  will,  by  separating  or  approxin)atiiig  the 
two  edges  of  the  fistula,  either  make  his  urine  emerge  from  the  artificial 
orifice,  or  cause  it  to  traverse  the  whole  extent  of  the  urethra.  Both  por- 
tions of  the  canal  were  affected  with  gonorrhoea. 


64  URETHRAL    GONORRHOEA    TN    THE    MALE. 

Ricord  administered  copaiba  to  this  patient,  and  directed  him  to  pass 
liis  water  entirely  through  the  fistula.  In  the  course  of  a  few  days,  the 
disease  was  cured  in  the  posterior  portion  of  the  canal,  behind  the  artificial 
opening  through  which  the  urine  had  passed,  while  it  remained  unchanged 
in  the  anterior  portion.  He  was  now  directed  to  make  his  water  pass 
through  the  wdiole  length  of  the  canal,  and  in  a  few  days  more  the  ante- 
rior portion  was  also  cured.  By  a  singular  coincidence,  two  other  cases 
of  a  similar  character,  soon  after  presented  themselves  in  Eicord's  wards, 
in  one  of  which  copaiba,  and  in  the  other  cubebs,  was  given  in  the  same 
manner,  and  the  result  in  each  was  the  same  as  in  the  case  just  described. 
From  these  experiments,  Ricord  concludes  that  copaiba  and  cubebs  have 
but  little  influence  upon  gonorrhoea,  unless  directly  applied  through  the 
urine  to  the  diseased  surface,  and  hence  we  cannot  expect  decided  benefit 
from  their  administration  in  any  form  of  gonorrhoea,  except  that  of  the 
urethra  in  the  two  sexes.  In  gonorrhoea  of  the  vagina  or  vulva,  or  in 
balanitis,  they  are  comparatively  useless. 

The  presence  of  these  drugs  in  the  urine  is  still  furtlier  evinced  by  the 
odor  which  they  impart  to  this  fluid,  and  which  is  often  sufficient  to  per- 
vade the  bed-chamber  occupied  by  the  patient. 

It  must  not,  however,  be  inferred  that  copaiba  and  cubebs  have  no  effect 
except  by  way  of  the  kidneys.  They  are  often  used  Avith  benefit  in  other 
diseases  than  those  of  the  urinary  organs,  and  cannot  therefore  be  entirely 
destitute  of  action  through  the  general  circulation.  Moreover,  they  some- 
times act  as  revulsives  by  producing  copious  evacuations  from  the  bowels, 
and  the  urethral  discharge  is  diminished  as  after  the  administration  of  a 
purge;  their  chief  action,  however,  is  in  the  manner  described,  by  their 
pi'esence  in  the  urine. 

Such  being  the  case,  it  might  naturally  be  supjjosed  that  an  emulsion  of 
copaiba  injected  into  the  urethra  would  have  the  same  effect,  and  that  thus 
the  internal  administration  of  so  nauseous  a  drug  might  be  avoided.  The 
experiment  has  been  tried  in  numerous  instances,  but  the  result  has  always 
been  unsatisfactory.  As  stated  by  Ricord,  both  copaiba  and  cubebs,  in 
passing  tlirough  the  digestive  organs  or  kidneys,  undergo  some. modifi- 
cation of  an  unknown  character,  upon  which  their  curative  power  depends, 
and  which  cannot  be  imitated  by  art. 

Dr.  Hardy,  of  Paris,  is  said  to  have  effected  a  cure  in  several  cases  of 
vai-inal  gonorrhoea  by  giving  the  patients  copabia,  and  directing  them  to 
inject  their  urine  into  the  vagina  after  each  act  of  micturition.  This 
course,  however,  is  more  interesting  as  an  experiment  than  worthy  of  imi- 
tation in  practice. 

M.  Roquette,  of  Nantes,  states  that  he  has  cured  two  patients  Avho  hap- 
pened to  be  rooming  together,  by  giving  copaiba  to  one  of  them  and 
directing  the  other  to  inject  his  friend's  urine.'  Testimony  on  this  point, 
however,  is  not  uniform.     In  the  Gaz.  med.  de  Lyon,^  Diday  says :  "We 

•  Accidents  determines  par  le  copahn,  Union  med.,  Paris,  dec.  19,  1854. 
2  June  IG,  1803. 


COPAIBA    AND    CUBEBS.  65 

seize  the  present  occasion  to  confess,  that  injections,  and  'even  the  reten- 
tion within  the  urethra,  of  urine  containing  copaiba — a  mode  of  treatment 
proposed  by  ourselves  in  1843 — has  not  had  in%ur  hands  the  same  success 
as  reported  by  other  authors,  or  as  theoretical  considerations  would  lead 
us  to  expect." 

Zeissl  has  experimented  with  inhalations  of  the  ethereal  oil  of  copaiba 
and  other  anti-blennolThagics,  in  a  few  cases,  and  states  their  action  to 
have  been  favorable  but  slow. 

It  was  formerly  supposed  that  copaiba  could  be  used  Avith  safety  only  in 
gleet,  and  even  then  in  very  small  doses,  and  that  it  was  inadmissible  in 
gonorrhoea,  especially  in  the  acute  stage,  having  a  tendency,  as  was  thought 
to  excite  inflammation  of  the  neck  of  the  bladder  and  swelled  testicle.  In 
the  latter  part  of  the  last  century,  however,  it  was  discovered  that  the 
natives  of  South  America  were  in  the  habiL  of  administering  copaiba 
in  large  doses  in  all  stages  of  gonorrhcea,  and  this,  too,  with  very  great 
successT'  This  led 'to  a  bolder  method  of  administering  it,  and  it  was 
soon  ascertained  that  its  curative  effect  is  much  greater  in  the  acute  than 
in  the  clironic  form  of  urethritis,  and  that  it  ise'rarely.  if  ever,  produc- 
tive of  those  complications  which  were  once  attributed  to  it.^  In  short,  it 
would  appear  that  copaiba  can  be  administered  with  safety  and  to  much 
greater  advantage  in  the  acute  stage  of  gonorrhcea,  or  at  an  early  period 
of  the  stage  of  decline  than  afterward,  and  the  same  is  true  of  cubebs. 
Still,  when  a  case  of  this  disease  presents  itself  with  marked  inflammatory 
symptoms,  it  is  usual  to  wait  for  a  day  or  two  until  these  have  been  some- 
what subdued  by  the  means  already  mentioned  bafore  commencing  with 
copaiba  or  cubebs,  and  I  do  not  think  that  any  time  is  thus  lost ;  and,  in 
all  cases,  the  effect  of  the  remedy  is  promoted  by  the  previous  exhibition 
of  a  cathartic.  The  diuretics  and  alkalies,  spoken  of  in  connection  with 
the  acute  stage,  may  be  combined  with  these  drugs,  as  in  some  of  the 
formulas  to  be  mentioned  presently,  or  they  may  be  given  separately. 

The  dose  of  copaiba  is  from  twenty  minims  to  one  or  even  two  drachms, 
repeated  three  times  a  day.  It  may  be  given  in  its  pure  form  upon  coffee, 
wine,  or  milk,  but  it  is  so  disagreeable  to  the  palate,  and  so  likely  to  ex- 
cite nausea,  eructations,  and  eyen  vomiting,  that  few  persons  can  thus 
tolerate  it.  To  render  it  more  acce])table  to  the  taste  and  stomach,, it  is 
generally  given  in  combination  ;  and  other  ingredients  are  often  added  for 
the  purpose  of  assisting  its  action  upon  the -urethra.  The  "Lafayette 
mixture"  in  common  use  may  be  made  more  acceptable  to  the  palate  by 
the  addition  of  extract  of  liquorice,  as  follows  : — 

'  For  ail  interesting  history  of  the  remarkable  change  in  medical  opinion  with 
regai'd  to  the  atlrninistration  of  copaiba,  see  Trousskav,  Traite  de  therapeutique, 
vol.  ii,  p.  592. 


66  URETHRAL    GONORRHCEA    IN    THE    MALE. 

R.     Copaiba?  §j 3000 

Liqiioris  Potassre  J^ij SiOO 

Ext.  GlycjiTliiza?'§ss Is'oO 

Spiritus  iEtheris  Nitrici  ?j        ...       25100 

Syrupi  Acaciae  §vj 225  00 

Olei  Gaiiltheria'  gtt.  xvj        ....         1  20 
Mix  tlie  copaiba  and  the  liquor  potassse,  and  the  extract  of  liqiiorice  and  sweet 
spirits  of  nitre  separately,  and  then  add  the  other  ingredients. 
Dose. — A  tablespoonful  (15.00)  after  each  meal. 

The  following  are  also  useful  formulas — 

R.     Olei  Copaibae,  I 

"    Cubeb;e,  aa  5j 4'00 

Alumiuis  gij 8  00 

Sacchari  albi  ,::^iv 16:00 

Mucilaginis  3iij 13100 

Aquje  |ii COloO 

M. 
Dose. — A  teaspoonful  (5.00)  three  times  a  day. 
^.     Copaibse, 

Liquoris  Potassas,  aa  5iij      •     •     •      •       12  00 

Mucilaginis  Acaciaj  ^j 3S  00 

Aquae  Menthse  Viridis  q.  s.  ad  §vj      .     200  00 
M.  (Milton.) 

Dose. — One  ounce  (30.00)  three  times  a  day. 

R.     Copaibje  3x 40  00 

Tincturae  Cantharidis, 

Tincturae  Ferri  Chloridi,  aa  5ij     •     •         ^  00 
M. 
Dose. — From  half  a  teaspoonful  (2.50)  to  a  teaspoonful  (5.00). 

IJ..    Syrupi  Acacia>  |v 190  00 

Vini  Opii  |j 30,00 

Olei  .Juniperi,  « 

Olei  Cubebai,  aa  5ij 8  00 

Copaibae  3iij 12  00 

Spiritus  Gaultheriae  Ji 30,00 

M. 
Dose. — A  teaspoonful  (5.00)  three  to  four  times  a  day.     (Dr.  Hollywood,  of 
Detroit.) 

But  in  whatever  way  combined,  many  stomachs  will  not  tolerate  copaiba 
in  a  liquid  form  ;  in  which  case  we  may  prescribe  the  solidified  mass,  formed 
by  the  addition  of  magnesia,  and  known  in  the  U.  S.  Dispensatory  as 
Piluhe  Copaibte.  It  requires  some  little  tact  to  prepare  this  mass;  or, 
rather,  ditliculty  is  met  with,  unless  the  proper  kind  of  copaiba  be  used. 
Two  kinds  of  the  balsam  are  found  in  commerce,  one  of  which,  the  best,  is 
solidifiable  with  magnesia,  and  the  other  not.  The  solidified  mass  should 
be  divided  into  i)ills,  each  of  which  may  contain  five  grains ;  and  it  is 
desirable  to  coat  them  with  sugar,  both  for  the  purpose  of  preventing  their 
adhering  together,  and  to  render  them  more  acceptable  to  the  palate.  This 
is  to  be  accomplished  in  the  following  manner :  Put  the  pills  into  a  vessel 
with  sufficient  water  to  moisten  them ;  then  turn  them  out  upon  a  pan  and 
sprinkle  over  them  finely  powdered  sugar,  at  the  same  time  rolling  them 
about  by  shaking  the  pan,  so  that  they  may  be  entirely  and  equally  coated. 
This  process  may  be  repeated  after  they  are  dry,  as  many  times  as  is  neces- 
sary to  give  them  a  thick  coating  of  sugar.     The  dose  is  from  four  to  eight 


COPAIBA    AND    CUBEBS.  67 

pills  three  times  a  day.  Thus  prepared,  they  leave  no  taste  in  the  mouth, 
and,  being  slowly  dissolved  in  the  stomach,  are  much  less  likely  to  excite 
nausea  than  the  liquid. 

We  have  another  anti-blennorrhagic,  but  little  if  at  all  inferior  to  copaiba, 
in  the  powdered  berries  of  the  Piper  Cubeba.  Cubebs  possess  the  advan- 
tage over  copaiba  of  being  far  less  disagreeable  to  the  taste,  and  less  likely 
to  excite  nausea,  eructations,  vomiting,  and  diarrhcea ;  and,  on  this  account, 
are  often  to  be  preferred  in  the  treatment  of  gonorrhoea.  They  cannot  be 
relied  upon,  however,  unless  freshly  powdered,  and  preserved  in  a  glass 
vessel,  since  the  essential  oil  which  they  contain  is  rapidly  absorbed  by 
any  porous  material.  Cubebs  are  conveniently  taken,  mixed  in  sweetened 
water,  in  the  proportion  of  one  to  two  drachms  of  the  powder  to  half  a 
glassful  of  the  liquid ;  and  this  dose  should  be  repeated  three  or  four  times 
a  day. 

Cubebs  are  often  advantageously  combined  with  iron,  especially  for 
persons  of  weak  habit,  thus  : — 

:^.    Pulveris  Cubebs  5ij 8100 

Ferri  Carbonatis  3ss 2100 

M. 
To  be  taken  three  times  a  day. 

Cubebs  and  copaiba  may  be  combined  together  in  the  same  prescription. 

^.    Copaibfe  .^ij 60  00 

Pulveris  Cubebse  |j 30  00 

Aluminis  3iss GJOO 

Magnesise  q.  s.  ut  fiat  massa. 
To  be  divided  into  pills  containing  five  grains  each  (0.32),  of  which  from  four 
to  eight  are  to  be  taken  three  times  a  day. 


;^.    Pulveris  Cubebfe  Jiij 90 

Copaibfle  §iss 45 

Aluminis  ,^ij 8 

Sacchari  albi  ^j 30 

Magnesire  5iss 6 

Olei  Cubebse, 

Olei  Gaultherise,  aa  gj 4 

M. 


This  mixture  is  known  as  "  the  Black  Paste,"  and  the  patient  may  be 
directed  to  take  a  piece  the  size  of  a  walnut,  after  each  meal.  The  follow- 
ing prescription  is  particularly  adapted  to  delicate  stomachs  : — 

^.    Copaibje.^ij 60  00 

Magnesife  3j 4  00 

Olei  Menthjc  Piperitje  gtt.  xx      ...  1  30 

Pulveris  Cubeb.-e, 

liismutlii  Subnitratis,  ail  §ij  .     .     .     .  COJOO 

M. 
To  be  divided  into  pills  of  five  grains  each  (0.32),  and  coated  with  sugar. 

I^.    Copaiba;  ^j 30  00 

Magnesife  3ss 2  00 

Pulveris  Cubcb.T  giss 4.')  00 

Aiinnonia'  Carbonatis  5i.i ^  *^t> 

Ferri  Sulpbatis  ^j ^  ^^ 

M.  "  (M<^ot.) 

To  be  divided  into  pills  of  five  grains  each  (0.32);  dose,  three,  three  times  a  day. 


68  URETHRAL    GONORRHOEA    IN    THE    MALE. 

Copaiba  and  cubebs  may  also  be  obtained  enveloped  in  capsules  of 
gelatine,  and  this  is  a  popular  form  of  administration.  The  capsules  obviate 
the  disagreeable  taste  of  these  drugs,  but  they  do  not  always  prevent  nausea 
and  eructations,  when  their  contents  are  suddenly  discharged  into  the 
stomach,  by  the  solution  of  the  envelope.  In  such  cases,  we  may  employ 
the  French  dragees  which  have  been  introduced  witliin  the  last  few  years, 
and  of  which  there  are  several  varieties;  some  containing  copaiba  alone, 
some  copaiba  and  tar,  others  cubebs,  and  others  still  both  these  drugs  com- 
bined with  iron ;  I  have  found  them  all  to  be  very  reliable.  The  dose  is 
from  four  to  six,  three  times  a  day. 

Cullerier  expresses  the  opinion,  which  is  endorsed  by  Fournier,  that  it 
is  sometimes  advantageous  to  alternate  doses  of  cubebs  and  copaiba. 
"  Give,  for  instance,  six  capsules  of  copaiba  in  the  morning,  six  of  cubebs 
during  the  day,  and  six  of  copaiba  at  night;  the  next  day,  commence  with 
the  cubebs,  and  so  on.  This  method  of  administering  these  drugs,  simple 
as  it  may  appear,  is  of  great  service,  and  I  would  recommend  it  whenever 
a  case  of  clap  does  not  yield  to  copaiba  and  cubebs  given  separately" 
(Cullerier). 

The  "Matico  Capsules,"  manufactured  in  New  York,  contain  copaiba, 
oil  of  cubebs,  the  ethereal  extract  of  cubebs,  gallic  acid,  and  morphine. 
In  these,  as  in  the  "matico  injection,"  the  "matico"  is  represented  only 
by  gallic  or  tannic  acid  in  small  proportions,  the  active  ingredients  being 
those  well  known! 

Injections  of  an  emulsion  of  copaiba  into  the  rectum,  when  the  drug  is 
not  borne  by  the  stomach,  have  been  recommended,  especially  by  Velpeau. 
I  have  never  tried  this  method  of  administering  copaiba,  and  should  have 
but  little  faith  in  its  efficacy.  It  is  acknowledged  that  a  much  large/ 
quantity  must  be  used  than  when  it  is  given  by  the  mouth.  A  simple 
injection  should  first  be  employed  to  clear  the  rectum  of  fecal  matter, 
when  the  followinn;  mixture  is  to  be  thrown  in  : — 


]^.    Copaihffi  3v 20 

Ovi  Vitelli  No.  j. 

Extract!  Opii  gr.  j 0 

Aqiije  §vjss 195 

M. 


00 


The  nausea,  eructations,  and  diarrha?a,  which  are  often  excited  by 
copaiba,  have  already  been  referred  to,  and  sometimes  render  it  impossible 
to  administer  this  remedy  in  any  form  to  a  delicate  stomach.  The  diar- 
rhoea may  often  be  controlled  by  the  combination  of  alum  or  an  opiate,  but 
more  frequently  requires  the  drug  to  be  suspended,  and  afterward  resumed 
in  smaller  doses. 

Copaiba  sometimes,  also,  gives  rise  to  a  cutaneous  eruption,  belonging 
to  the  class  of  exanthemata,  as  roseola,  erythema,  or  urticaria.  Such  erup- 
tions should  be  carefully  distinguished  from  those  of  secondary  syphilis, 
as  may  readily  be  done  by  the  absence  of  coexisting  syphilitic  symptoms, 
by  the  itching  that  usually,  but  not  always,  attends  them,  and  by  their 
disappearance  in  a  few  days  after  the  copaiba  is  suspended.    The  adminis- 


COPAIBA    AND    CUBEBS.  69 

tration  of  copaiba  should  not,  as  a  rule,  be  continued,  if  it  produce  this 
effect,  although  Diday  says  that  the  eruption  will  disappear  spontaneously 
all  the  same  whether  we  go  on  with  tlie  copaiba  or  not. 

Another  unpleasant  symptom  not  unfrequently  occasioned  by  copaiba, 
is  pain  in  the  region  of  the  kidneys,  dependent  upon  congestion  of  those 
organs.  A  few  years  ago,  a  patient  was  under  my  care  for  gonorrhoea, 
who  had  previously  had  several  attacks  of  ha^maturia.  Contrary  to  my 
advice,  he  took  copaiba,  which  induced  a  return  of  the  blood  in  his  urine, 
and  I  afterwards  learned  that  the  administration  of  this  drug  had  already 
produced  a  similar  effect  in  a  former  attack  of  gonorrhoea.  This  and  other 
similar  instances  may  readily  be  explained  on  the  probability  that  copaiba 
and  cubebs  produce  a  certain  amount  of  hypera^mia  of  the  kidneys.  But 
a  far  more  serious  charge  has  been  brought  against  these  drugs,  viz. :  that 
of  producing  morbus  Brightii.  Now  there  is  no  evidence  whatever  that 
this  charge  is  well  founded.  Zeissl  states  that  in  his  large  experience,  he 
has  found  no  proof  of  the  same,  and  this  is  our  own  testimony  and  that  of 
others  well  informed.  The  error  has  probably  arisen  from  the  fact  that 
the  urine  of  persons  taking  copaiba  will,  on  the  addition  of  nitric  acid, 
deposit  a  sediment  which  has  been  mistaken  for  albumen.  That  it  is  not 
albumen  is  shown  by  its  disappearance  on  boiling,  or  on  addition  of  alcohol, 
potash  or  carbonate  of  ammonia.  It  is  merely  due  to  the  copaibic  acid 
contained  in  the  urine. 

Cubebs  may  occasion,  though  much  more  rarely,  any  of  the  unpleasant 
symptoms  just  mentioned  as  likely  to  occur  from  copaiba.  Both  of  these 
drugs,  in  large  doses,  will,  in  rare  instances,  excite  severe  headache, 
giddiness,  and  even  more  serious  symptoms  connected  with  the  nervous 
centres.  Ricord  mentions  a  case  of  temporary  hemiplegia,  and  another  of 
violent  convulsions,  produced  by  copaiba ;  in  both  instances,  these  serious 
symptoms  were  followed  by  the  outbreak  of  a  cutaneous  eru[)tion,  also 
dej)endent  on  the  drug. 

The  anti-blennorrhagics  now  mentioned,  are  of  undoubted  efficacy  in 
the  treatment  of  many  cases  of  gonorrhoea,  but  in  others  they  utterly  fail ; 
nor  have  we  any  means  of  distinguishing  these  two  classes  of  cases  before- 
hand. As  a  general  rule,  if  they  are  likely  to  prove  successful,  their  good 
effect  will  be  apparent  in  a  fortnight  or  three  weeks  from  their  commence- 
ment, and  if,  by  this  time,  the  disease  continue  unabated,  they  should 
be  omitted,  and  other  means  employed  to  effect  a  cure.  When  long 
continued,  they  ])roduce  disorder  of  the  digestive  functions,  impair  the 
appetite,  and  induce  general  malaise  and  debility  ;  a  condition  of  the  sys- 
tem highly  calculated  to  prolong  the  duration  of  gonorrhoea.  Though 
often  of  marked  btenefit,  they  are  by  no  means  indispensable  in  the  treat- 
ment of  every  case  of  gonorrlnx^a. 

Preparations  of  the  Gelsemium  senipervii'ens  are  mucii  employ(Ml  at  the 
South,  given  internally,  in  the  treatment  of  gonorrluea,  but  in  my  hands 
have  not  proved  of  much  benelit.  This  jdant  acts  primarily  on  the  nerv- 
ous centres,  and  in  full  doses  produces  staggering  in  the  gait,  dimness  of 
sight,  and  double  vision.     In  one   of  my  patients  who  was  taking  it,  the 


70  URETHRAL    GONORRHCEA    fN    THE    MALE. 

double  vision  was  due  to  paralysis  of  the  motor  oculi  of  each  eye,  which 
passed  off  soon  after  the  drug  was  suspended.  The  most  convenient  form 
for  administration  is  the  fluid  extract,  the  dose  of  which  is  about  fifteen 
drops  three  times  a  day,  gradually  increased  until  dimness  of  vision  or 
staggering  in  the  gait  is  perceived. 

The  following  formula  is  recommended  by  Prof.  Wm.  P.  Seymour,  of 
Troy  :- 

R.     Ext.  Gelsemii  fl.  Sij 8100 

Spiritus  ^Etheris  Nit.  |ij       ....  55  00 

Tinct.  Cubebfe  gj 30|00 

Spt.  Lavaiidul?e  Comp.  §ss  ....  15|00 

Aquse  q.  s.  ad  §iv 120|00 

M-     3J  (4.00)  every  six  or  eight  hours. 

The  oil  of  yellow  sandal  wood  is  a  very  valuable  internal  remedy  for 
gonorrhoea,  which  was  first  introduced  to  the  notice  of  the  profession  in 
1865,  by  Dr.  Thomas  B.  Henderson,  of  Glasgow.^  I  have  found  it  quite 
as  efficacious  as  copaiba,  if  not  more  so,  and  it  is  far  more  acceptable  to 
the  stomach.  The  dose  is  from  fifteen  to  tliirty  minims,  three  times  a 
day,  taken  on  lumps  of  cut  sugar,  in  water,  or  in  a  mixture  with  alcohol 
and  cinnamon — 

R.     Olei  Santali  Flavi  §j      ......     32100 

Spiritus  recti  giij 90:00 

Olei  Cinnamomi  f»\,xxiv l|CO 

M.  et  Sig. — From  one  to  two  teaspoonfuls  (5.00-10.00)  tlii-ee  times 
a  day. 

This  oil  is  now  put  up  in  capsules  ;  from  twelve  to  twenty  are  to  be 
taken  daily. 

I  have  known  of  a  number  of  cures  of  gonorrhcea  with  the  oil  alone. 
Sometimes,  like  copaiba,  it  produces  pain  in  the  kidneys,  and  must  be 
suspended.'^ 

I  have  tried  the  oil  of  erigeron  as  recommended  by  Dr.  J.  T.  Pretty- 
man,  but  without  favorable  result.* 

Gurjun  Balsam  has  recently  been  prescribed  with  success  at  some  of 
the  hospitals  of  Paris.*  It  is  said  to  act  more  rapidly  than  copaiba,  and 
to  have  no  disagreeable  effect  on  the  breath. 

The  following  is  Vidal's  formula,  as  used  at  the  Hopital  St.  Louis  : — 

Gurjiin  Balsam  4  grammes  (1  drachm)  ; 

Gum  4  grammes  (1  drachm)  ; 

Infusion  of  Star  Anise  40  grammes  (10  drachms). 

To  be  divided  into  two  doses,  and  taken  directly  before  meals. 

1  can  speak  very  favorably  of  Cannabis  sativa  as  an  internal  remedy 
for  gonorrhoea  after  the  more  acute  symptoms  have  subsided.  It  is  to  be 
given  in  the  form  of  the  mother-tincture  (one   part  of  the  fresh  plant  to 

'  Glasgow  Medical  Journal,  1865. 

2  See  articles  by  M.  Panas,  Union  nied.,  Paris,  Sept.  23,  1805;  and  by  Dr.  H. 
H.  A.  Beach,  Bost.  Med.  and  Surg.  Journ.,  Nov.  5,  1808. 

*  Am.  Journ.  Med.  Sci.,  July,  1860. 

«  Bull.  gen.  de  tlierap.,  Paris,  Feb.  28,  1878. 


EXPECTANT    TREATxMENT.  71 

two  parts  of  alcohol,  by  weight),  in  doses  often  to  fifteen  drops,  in  water, 
three  or  four  times  a  day. 

During  the  administration  of  copaiba,  cubebs,  or  any  other  drugs  which 
act  by  their  presence  in  the  urine,  the  patient  should  drink  but  little  fluid, 
so  that  the  urine  may  be  undiluted  and  as  fully  charged  as  possible  with 
the  remedy. 

Expectant  Treatment In  a  work  like  the  present,  which  is  intended  to 

give  the  views  of  other  authors  as  well  as  our  own,  it  would  be  unjust 
to  the  reader  to  omit  saying  that  the  treatment  above  recommended  is 
in  several  respects  at  variance  with  that  advised  by  some  authorities  of 
the  highest  eminence.  I  refer  to  the  present  teachings  of  the  French 
school,  and  especially  to  those  of  Fournier  and  Diday. 

The  treatment  adopted  by  these  surgeons  is,  to  a  great  extent,  an  ex- 
pectant treatment,  and  may  be  stated  as  follows  :  In  the  first  place  they 
do  not  believe  in  the  efficacy  of  copaiba  and  cubebs,  nor  in  urethral  in- 
jections during  the  acute  stage  of  the  disease,  or  even  Avhile  any  decidedly 
puriform  discharge  remains.  They  believe  that  these  means  may  repress 
the  discharge  for  the  time  being,  but  that  the  latter  will  return  in  full 
force  as  soon  as  the  former  are  stopped  ;  moreover  that  their  use  at  this 
time  so  habituates  the  stomach  and  urethra  to  them,  that  they  can  be  used 
to  much  less  advantage  at  a  later  period,  when  their  action  would  other- 
wise be  speedily  effectual.  Hence,  Diday  lays  down  the  following  rule : 
"  Tell  every  patient  who  comes  to  you  at  a  time  when  the  acute  stage  of 
clap  is  established,  that  he  must  wait  a  month  or  six  weeks  before  it  is 
possible  to  give  him  specific  remedies  with  advantage."^ 

Meanwhile,  while  waiting  for  the  clap  to  become  "  ripe"  enough,  as 
Diday  expresses  it  (to  be  plucked  ?),  these  surgeons  prescribe  attention  to 
hygiene,  "  a  full  bath  every  third  day,"  **  several  local  baths  of  cold  water 
daily,"  "avoidance  of  beer,  white  wines,  and  Vermouth;"  "pure  wine, 
coffee,  liqueurs,  pork,  and  spiced  dishes  only  in  moderation,"  together 
with  "  a  glass  of  water,  four  or  five  times  a  day,  either  sweetened  with 
syrup  or  orgeat,  or  with  a  pinch  of  the  following  powder : — 

I^.     Sacch.  albi, 

Pulv.  Acacire,  ail  §ij 60 

"     Glycyrrliiz?e, 

"     Potass.  Nitrat.  aa  giss   ....       G 
M." 

If  in  spite  of  this  treatment  the  inflammation  should  increase,  without, 
however,  attaining  its  maximum  intensity,  "  Order  five  or  six  glasses  a 
day  of  a  ptisan  of  couch-grass  (^chiendent),  and  strawberry  root  (racine  de 
Jraisier),  sweetened  with  syrup  of  liquorice.  Every  second  day,  before 
going  to  bed,  take  a  bath  and  remain  in  it  for  an  hour  and  a  half.  Two 
or  three  times  a  day,  bathe  the  penis  with  a  warm  infusion  of  marshmallow. 
S{)rinkle  the  inside  of  the  suspensory  bandage  worn  with  powdered  cam- 
phor, "  etc.  etc.  etc. 

'  Th6rapeutic|uo  dos  mal.  ven,,  1876,  p.  12. 


12  URETHRAL  GONORRH(EA  IN  THE  MALE. 

When  the  inflammation  has  reached  its  height,  "  ap])ly  eight  leeches 
to  the  perinajum.  Kemain  in  bed  or  at  any  rate  in  your  room.  When 
walking  keep  the  penis  elevated.  Drink  two  or  three  pints  daily  of  flax- 
seed tea,  or  a  ptisan  of  the  white  water-lily.  Take  a  full  bath  every  day, 
lasting  from  two  to  three  hours.  Frequent  local  baths  of  an  infusion  of 
marslmiallow.  Pass  water  with  the  penis  immersed  in  warm  water. 
Avoid  every  occasion,  physical  and  moral,  for  erections.  Keep  your  hoioels 
open. 

"  A  clap  must  not  be  considered  ripe,  simply  because  such  time  has 
passed  as  is  regarded  as  the  ordinary  term  by  the  patient,  influenced  by 
theoretical  considerations,  prejudices  or  his  own  convenience.  Each  clap 
has  its  own  course  ;  and  although  we  may  usually  reckon  on  five  or  six 
weeks  for  it  to  attain  maturity,  this  period  is  sometimes  shorter,  and  very 
often  longer;  frequently  it  amounts  to  two  months  and  a  half  or  three 
months,  and  in  one  case  under  my  care  it  was  eleven  months !  How  shall 
we  ascertain  that  a  clap  is  ripe  ?  It  is  ripe  when  there  is  little  or  no  pain  in 
passing  water  and  in  erections,  Avhen  the  meatus  is  no  longer  red  nor  tume- 
fied ;  when  the  discharge  has  much  diminislied,  and,  instead  of  being  yellow 
or  green,  is  white  and  somewhat  sticky.  This  last  feature  is  characteristic, 
and,  since  it  cannot  appear  without  the  other  signs  of  maturity  existing, 
it,  of  itself,  is  a  resume  of  all  the  signs,  in  a  diagnostic  point  of  view ;  so 
much  so  that,  in  any  case  of  claj),  if  the  discharge,  collected  a  sufficiently 
long  time  after  an  erection  and  held  between  two  fingers,  xvill  stretch  be- 
tween them  as  they  are  separated  to  the  extent  of  four-tenths  of  an  inch 
(metre  0.01),  we  are  authorized  to  pronounce  that  clap  ripe"  (Diday, 
loc.  cit.). 

The  clap  having  been  found  or  supposed  to  be  "ripe,"  copaiba  and  cubebs, 
aided  or  not  by  urethral  injections,  are  to  be  used  vigorously  for  a  week  or 
a  fortnight.  If,  after  the  lapse  of  this  time  the  patient  is  not  well  or  his 
discharge  nearly  gone,  "  stop  the  treatment  at  once,  its  continuance  would 
be  a  mistake  ;  the  reason  it  did  not  succeed  was  that  it  was  premature  ; 
make  up  your  mind  then  to  wait  ;  return  for  a  time  to  demulcent  drinks ; 
then  try  again  suppressive  medication,  as  soon  as  it  shall  appear  to  be  in- 
dicated" (Fournier).  Copaiba  and  cubebs  would  appear  to  be  more 
relied  upon  by  these  surgeons  and  others  of  the  French  school  than  ure- 
thral injections.  The  statements  of  patients  are  always  to  be  taken  cum 
grano  salis;  hence  I  cannot  fully  rely  upon  the  word  of  a  recent  patient 
returning  from  Paris  who  said  an  eminent  French  surgeon  told  him  that 
urethral  injections  were  nearly  obsolete  in  France. 

As  said  in  commencing,  the  above  treatment  recommended  by  Fournier 
and  Diday  is  in  the  main  expectant.  Aside  from  rest  and  hygiene,  the 
means  recommended  while  waiting  for  the  claps  to  become  "ripe"  can  have 
little  if  any  efiect.  I  will  not  say  but  their  course  is  the  best.  The  cases, 
which  everybody  meets  with,  of  a  clap  hanging  on  month  after  month 
under  ordinary  treatment,  are  enough  to  lead  us  to  try  anything  which 
promises  better  success.  But  1  have  never  been  able  to  tborougldy  test 
their  treatment,  simply  because  patients  will  not  submit  to  such  temporiz- 


OBSTACLES    TO    SUCCESS.  73 

ing.  I  Avould  not  myself  if  I  had  the  disease,  nor  would  you,  virtuous 
reader,  if  you  should  chance  to  "contract  a  clap  from  a  water-closet"  (or 
otherwise).  At  the  same  time,  the  experience  of  these  surgeons  may  in- 
duce us  to  inquire  in  many  cases  whether  medication  has  not  been  carried 
too  far. 

Obstacles  to  Success — A  mistake,  generally  committed  by  patients  who 
treat  themselves  for  gonorrhoea,  and  by  some  physicians,  especially  in  the 
early  years  of  their  practice,  is  over-medication  and  a  neglect  of  the  gene- 
ral health.  Nothing  is  more  common  than  to  meet  with  a  patient,  suffer- 
ing with  gonorrhoea  of  several  months'  standing,  who  has  been  kept  on  low 
diet,  and  been  taking  various  preparations  of  copaiba  and  cubebs,  using  a 
variety  of  injections  often  exceedingly  irritant  in  their  composition  or 
strength,  and  who  is  now  run  down,  weak  in  body,  and  despairing  in  mind. 
His  digestion  is  impaired,  his  appetite  gone,  and  his  clap  as  bad  as  ever. 
Let  such  a  man  lay  aside  his  capsules,  pills,  powders,  mixtures,  and  irri- 
tant injections  ;  give  him  substantial  food,  and  a  tonic,  as  quinine  or  iron ; 
and  his  disease  will  probably  begin  to  improve  at  once,  and  subside  en- 
tirely in  the  course  of  a  few  days  or  Aveeks.  Under  any  circumstances, 
you  will  have  removed  one  great  obstacle  to  a  cure,  and  if  the  discharge 
do  not  entirely  disappear,  it  is  probably  kept  up  by  some  local  complication, 
which  can  now  be  attacked  with  a  prospect  of  success. 

Independently  of  debility,  the  chief  causes  of  the  continuance  of  a  gonor- 
rhoea! discharge  are  the  existence  of  stricture  and  irritation  of  the  neck  of 
the  bladder.  It  is  desirable  in  every  obstinate  case  to  ascertain  if  the 
former  be  present  by  the  passage  of  bulbous  sounds,  and  if  any  obstruction 
be  met  with,  appropriate  treatment  should  at  once  be  adopted;  but  even 
in  the  absence  of  stricture,  the  introduction  of  an  instrument  into  the 
bladder  two  or  three  times  a  week  has  a  most  beneficial  effect  upon  old 
cases  of  clap.^ 

It  sometimes  happens  that  a  case  of  gonorrhoea  has  been  going  on  well 
for  a  week  or  ten  days  under  the  use  of  the  anti-blennorrhagics  and  injec- 
tions— the  discharge  has  almost  entirely  ceased,  and  the  patient  considers 
himself  nearly  well,  when  suddenly  a  relapse  takes  place  ;  the  discharge 
is  once  more  thick  and  purulent ;  the  scalding  in  making  water  returns  ; 
the  injection,  which  has  scarcely  been  felt  for  a  number  of  days,  excites 
considerable  pain,  and  at  the  same  time  the  patient  has  a  frequent  desire 
to  pass  his  urine,  and  suffers  from  an  uneasy  sensation  in  the  perineal  re- 
gion. The  latter  symptoms  dtuiote  that  the  disease  has  extended  to  the 
deeper  portion  of  the  urethra,  and  that  there  is  ii'ritation  or  inflammation 
of  the  neck  of  the  bladder.  Under  these  circumstances,  the  case  requires 
to  be  veuv  carefully  watched  and  judiciously  treated.  Unless  great  care  be 
used,  the  infiannnation  may  extend  through  the  vas  deferens  to  the  scrotal 
organs,  and  swelled  testicle  ensue  ;  or  the  prostate  gland  may  become  in- 
volved. If  irritant  injections  now  be  used,  they  will  prove  inefficient  and 
will  aggravate  the  symptoms.     It  is  best  to  suspend  the  use  of  injections 

■  See  chapter  on  Gleet. 


74  URETHRAL    GONORRH(EA    IN    THE    MALE. 

altogether,  and  to  resort  to  the  exhibition  of  alkalies  and  sedatives,  as 
recommended  in  the  inflammatory  stage,  until  the  subsidence  of  the  symp- 
toms shall  enable  us  to  resume  direct  treatment ;  the  patient  should  also 
be  particularly  careful  with  regard  to  exercise.  Canada  turpentine,  the 
product  of  the  Abies  baJsamea,  will  also  be  found  of  essential  service  in 
these  cases.  It  may  be  made  into  pills  containing  five  grains  each,  of  which 
from  six  to  twelve  should  be  taken  daily.  I  have  also  been  much  pleased 
with  the  effect  of  tincture  of  ergot,  administered  in  drachm  doses  three 
times  a  day. 

Treatment  of  Special  Symptoms — It  remains  to  speak  of  the  treatment 
of  certain  special  symptoms  which  may  attend  a  case  of  gonorrhoea,  and 
one  of  the  most  annoying  of  these  is  chordee.  Various  sedatives  are  em- 
ployed for  its  relief,  among  which  camphor  holds  the  first  rank.  This  may  be 
given  in  the  form  of  a  pill,  combined  with  extract  of  lettuce  or  opium,  as 
in  the  following  formuhe  : — 

I^.    Lactucarii, 

Pulveris  Campliorae,  aa  ^ij     ....       2]60 
M.  ft.  \V\\.  XX. 
Dose. — Two  at  bedtime.  (Ricord.) 

I^.    Pnlveris  Camplior?e  ^iss 2|00 

Pulveris  Opii  gr.  x |65 

M.  ft.  pil.  No.  X. 
Dose. — One  or  two.  (Ricord.) 

AVe  have  also  used  with  good  result  the  monobromide  of  camphor  in 
doses  of  three  grains  (gramme  0.20),  either  made  into  a  pill  with  the  ex- 
tract of  hyoscyamus  or  dissolved  in  the  tincture  of  the  same. 

Mr.  Milton  prefers  camphor  in  a  liquid  form  in  large  doses.  He  directs 
the  patient  to  take  one  drachm  of  the  tincture  in  water  on  going  to  bed, 
and  eveiy  time  he  wakes  up  with  chordee,  to  repeat  the  dose.  He  states 
that  after  the  continuance  of  this  treatment  for  two  or  three  nights  all 
tendency  to  chordee  disappears. 

Dr.  Ed.  R.  Mayer^  says  "  full  doses  of  gelsemium  at  bedtime  are  the 
most  certain  preventive  of  chordee." 

Lupuline  is  another  remedy  of  undoubted  power  in  allaying  the  excita- 
bility of  the  genital  organs,  and  possesses  the  advantage  over  opium  that 
it  does  not  constipate  the  bowels.  It  may  be  given  in  doses  of  fifteen 
grains,  triturated  in  a  mortar  with  sugar.  This  quantity  is  to  be  taken 
before  going  to  bed,  and  may  be  repeated  one  or  more  times  in  the  night 
if  required. 

Of  the  above  means  of  relieving  chordee,  I  regard  Mr.  Milton's  method 
of  giving  camphor,  if  it  do  not  disagree  with  the  stomach,  and  the  admin- 
istration of  lupuline,  as  the  best ;  yet  none  of  the  remedies  mentioned  can 
be  relied  upon  with  certainty  of  producing  the  desired  effect,  for  they  all 
fail  in  many  instances.  Much  may  be  accomplished  by  directing  the 
patient  to  avoid  eating  or  drinking  for  some  hours  before  going  to  bed,  to 

•  "Specific  Medication,"  a  paper  read  before  the  Luzerne  County  Medical  Soc, 
at  Pittston,  Pa.,  Sept.  13,  1876. 


TREATMENT    OF    HEMORRHAGE. 


75 


be  careful  to  empty  his  bladder  and  rectum,  and  to  sleep  on  a  hard  mat- 
tress, with  but  few  bed-clothes  over  him.  The  position  in  bed  is  also  of 
importance,  since  erections  are  much  less  likely  to  take  place  when  lying 
upon  the  side  than  upon  tlie  back.  Suppositories  of  the  extracts  of  opium 
or  hyoscyamus  and  belladonna  introduced  into  the  rectum  may  often  be 
found  of  service. 

Another  means  of  relief  wliich  I  have  found  highly  successful  is  bath- 
ing the  genital  organs  in  very  hot  water  directly  before  going  to  bed. 
The  reaction  after  the  application  of  heat  has  a  sedative  effect,  and  in  this 
respect  has  exactly  an  opposite  influence  to  that  of  the  cold  lotions  Avhich 
are  sometimes  advised. 

Many  French  surgeons  recommend  leeches  to  the  perinjeum.  I  have 
never  tried  them,  believing  the  remedy  Avorse  than  the  disease. 

Treatment  of  Hemorrhage — A  slight  hemorrhage  from  the  urethra  in 
gonorrhoea  is  often  a  blessing  rather  than  a  curse,  since  it  relieves  the  con- 
gested condition  of  the  vessels.  Even  when  so  great,  though  still  moder- 
ate in  amount,  as  to  require  precautionary  measures,  it  will  usually  be 
sufficient  to  put  the  patient  into  bed  with  his  hips  elevated,  and  apply  ice 
or  cloths  dipped  at  short  intervals  in  ice-cold  water  to  the  genitals.  If  at 
hand,  the  ingenious  "  cold-water  coil"  of  Dr.  Otis,  represented  in  Fig.  6, 
may  here  be  employed. 

Fiof.  6. 


Otis'g  cold-water  coil. 


In  severe  cases  we  are  obliged  to  resort  to  urethral  injections  of  very 
cold  water,  or  of  water  with  the  addition  of  some  strong  astringent  as  the 
perchloride  or  jjersulphate  of  iron.  These  means  will  rarely  fail,  but  we 
may  be  led  to  try  the  effect  of  a  full-sized  sound,  or  a  piece  of  a  flexible 
catheter  introduced  into  the  canal  and  a  comi)ressive  bandage  around  the 
penis.  A  compress  firmly  applied  by  a  bandage  to  the  perinaaum  or 
Otis's  perineal  tourniquet  will  take  the  place  of  this  when  the  blood  comes 


76  URETHRAL    GONORRHCEA    IN    THE    MALE. 

from  the  deep  uretlira.     Hoemostatics,   especially  ipecac   or  ergot  given 
internally,  will  do  no  harm. 

As  an  attack  of"  gonorrhoea  is  passing  off,  it  not  unfrequently  happens 
that  the  discharge  assumes  an  intermittent  character,  entirely  disappearing 
for  a  few  days,  and  then,  without  apparent  cause,  reappearing  for  a  day  or 
two.  This  may  occur  several  times  in  succession,  and  in  some  cases  that 
I  have  witnessed,  it  has  assumed  great  regularity.  The  surgeon  should, 
of  course,  assure  himself  that  the  return  of  the  symptoms  is  not  due  to  im- 
prudence, and,  if  satisfied  of  this,  is  generally  safe  in  telling  the  })atient 
that  his  disease  will  soon  cease  entirely  to  annoy  him. 

It  is  important  to  continue  treatment  for  some  days  after  all  traces  of 
the  disease  have  passed  away,  since  relapses  are  very  readily  induced. 
They  are  usually  brought  on  by  the  patient's  neglecting  the  rules  with 
regard  to  exercise,  diet,  etc.,  already  laid  down,  or  by  his  indulging  in 
sexual  intercourse.  He  should  be  particularly  cautioned  on  these  points, 
and  should  be  directed  to  continue  his  medication,  both  external  and  inter- 
nal, in  decreasing  doses,  for  at  least  ten  days  after  the  lips  of  the  meatus 
have  ceased  to  be  glued  together  in  the  morning.  Until  every  symptom 
of  gonorrhoea  has  disappeared  for  this  length  ol'  time,  the  patient  cannot 
consider  himself  as  securely  well,  and  should  still  be  cautious  in  his  habits 
for  a  fortnight  longer. 

After  the  entire  cessation  of  the  discharge,  patients  sometimes  complain 
of  abnormal  sensations  in  the  genital  organs,  which  they  describe  under  the 
names  of  "tickling,"  "crawling,"  and  sometimes  "lancinating,"  and 
which  may  be  nearly  constant  or  intermittent  at  intervals  of  several  hours 
or  several  days.  These  sensations  in  most  cases  are  not  dependent  upon 
inflammation  or  organic  changes  in  the  part,  but  are  of  a  strictly  neu- 
ralgic character.  They  are  best  relieved  by  the  passage  of  a  full-sized 
sound  every  few  days ;  and  they  are  much  less  felt  when  once  the  mind  is 
set  at  rest  with  regard  to  any  danger  of  a  return  of  the  gonorrhoea. 

The  reader  may  be  interested  to  know  what  is  the  average  duration  of 
treatment  required  in  the  hands  of  the  best  surgeons  for  the  cure  of  gonor- 
rhoea, laying  aside  those  cases  which  are  seen  in  the  first  stage,  and  which 
are  speedily  cured  by  the  abortive  method.  This  may  be  estimated  at 
four  to  six  weeks.  Greater  success,  on  the  average,  is  probably  not  attain- 
able by  any  means  with  wliich  we  are  at  present  acquainted. 

Although  I  have  been  led  in  the  preceding  pages  to  criticize  the  ex- 
pectant treatment  as  recommended  by  some  French  surgeons,  yet  I  cannot 
close  this  chapter  without  a  quotation  from  Fournier,  which  contains  much 
sound  common  sense.  He  says:  "We  meet  with  cases  of  gonorrhrjea 
Avhich  defy  all  treatment.  Shall  we  in  these  cases  persist  and  struggle  on, 
piling  one  remedy  and  one  injection  upon  another?  I  believe  that  this 
l)ractice  will  more  frequently  aggravate  the  disease  than  cure  it.  In  my 
opinion  it  is  better  to  desist,  to  stop  all  medication,  to  encourage  the 
patient  and  leave  to  time  what  art  has  not  been  able  to  accomplish.  I  am 
not  afraid  to  say  that  there  are  many  patients,  who,  after  exhausting  all 
the  resouixes  of  therapeutics,  get  well  through  time  alone.     Moreover,  in 


INCURABLE    GONORRH(EA.  77 

most  instances,  the  disease  subsides  into  a  mere  inoffensive  oozing  from 
the  canal.  It  is  better  to  put  up  with  a  small  evil  than  to  expose  one's 
self  to  a  worse  one  by  seeking  a  cure  which  remains  uncertain.  Now 
there  can  be  no  question  but  that  medication  continued  for  a  long  time, 
and  incessant  irritation  of  the  urethra,  may  result  in  serious  accidents  and 
in  grave  complications.  In  the  face  of  this  danger  springing  from  the 
treatment,  the  physician  must  know  when  to  stop  in  time.  Unable  to 
cure  in  every  case,  he  should  at  least  not  make  the  case  worse." 


78  GLEET. 


CHAPTER   II. 
GLEET. 

AVhat  is  the  difference  between  chronic  gonorrha'a  and  that  affection 
known  as  "  blennorrhoea"  or  "gleet"?  If  half  a  dozen  snrgeons  be  asked 
this  question,  it  is  not  probable  that  the  answers  of  any  two  of  them  will 
exactly  correspond,  and  this  because  a  gleet  is,  in  most  cases,  preceded  by 
a  gonorrhoea,  the  latter  terminating  in  the  former,  without  any  broad  line 
of  demarcation  between  them.  Yet  if  gleet  be  worthy  of  a  separate  name, 
it  must  possess  some  distinctive  features,  and  these  we  will  endeavor  to 
describe. 

Let  us  understand  then  by  gleet  a  chronic  discharge  from  the  urethra, 
unattended  by  pain,  or  other  symptoms  of  inflammation,  and  containing  only 
a  very  small  quantity  of  pus,  of  a  milky  or  opaline  color,  so  scanty  as  to 
be  seen  only  when  a  very  long  time  has  elapsed  since  passing  water,  as  in 
the  morning  on  rising,  when  the  lips  of  the  meatus  may  be  found  glued 
together,  and,  possibly,  a  small  drop  of  the  fluid  may  be  pressed  from  the 
canal.  At  other  times  the  fluid  is  absent  or  is  only  detected  by  the 
presence  of  long  shreds,  looking  like  vermicelli,  floating  in  the  urine. 
This  fluid  deposited  upon  the  linen,  leaves  a  diffused  grayish  patch,  slightly 
darker  (possibly  faintly  yellow)  at  the  centre.  Another  characteristic 
of  gleet  is  that,  unlike  chronic  gonorrhoea,  it  is  not  readily  lighted  up 
into  an  acute  stage  of  inflammation  by  excesses  in  diet  or  coitus,  although 
it  is  not  entirely  free  from  this  risk.^ 

In  addition  to  gleet,  we  might  admit  with  Diday,  still  another  chronic 
discharge  from  the  urethra,  which  is  characterized  by  its  entire  freedom 
from  pus  or  muco-pus  and  which  consists  merely  of  a  transparent,  viscous 
fluid,  that  can  be  stretched  to  some  distance  between  the  fingers.  Its  appear- 
ance is  not  constant  in  the  morning  as  is  the  discharge  of  gleet,  nor  does 
it  depend  upon  the  time  passed  since  urinating.  It  shows  itself  from  time 
to  time,  independently  of  erections,  and  especially  on  straining  at  stool, 
etc.,  and  the  lips  of  the  meatus  are  more  moist  than  they  used  to  be  (or 
than  the  patient  supposes  them  to  have  been).  In  short,  such  cases  should 
properly  be  included  under  tlie  head  of  "  prostatorrhtea,"  in  which  mental 
treatment  is  of  quite  as  much  importance  as  physical,  not  to  say  more  so. 

'  When  a  patient  lias  exposed  himself  in  coitus  and  has  observed  an  aggravation 
of  an  old  discharge,  the  question  often  comes  up,  whether  he  has  simi)ly  revived 
the  acute  stage  in  consequence  of  his  imprudence  or  has  contracted  a  fresh  clap. 
The  former  is  probably  the  case  if  the  aggravation  of  the  symptoms  appeared  the 
next  morning  after  exposure  ;  the  latter,  if  the  aggravation  has  been  delayed  a 
few  days  (Diday). 


DIAGNOSIS. 


T9 


The  recognition,  however,  of  these  three  chronic  urethral  discharges, 
viz.,  chronic  gonorrlioea,  gleet,  and  chronic  urethral  moisture  in  excess,  is 
of  such  importance  that  we  will  present  their  diagnostic  symptoms  in  a 
tabulated  form : — 


Chronic  Goxorkhcea. 

Objective  Si/mptoms. — If 
urine  lias  not  been  passed 
for  three  or  four  hours,  a 
whitish  or  yellow  drop 
may  be  pressed  from  the 
urethra.  Meatus  slightly 
reddened. 


Subjective  Sijmptoms. — 
Slight  pain  in  passing 
urine  and  in  erections. 


Liabilities. — The  dis- 
charge and  pain  aggra- 
vated temporarily  by  ex- 
cess in  diet,  coitus  or  other 
imprudence. 

Danger  of  contagion 
great. 


Gleet. 

Objective  Symptoms. — Dis- 
charge, seen  only  in  the 
morning,  is  of  a  milky  or 
opaline  white  color,  never 
decidedly  yellow.  Some- 
times merely  glues  the  lips 
of  the  meatus  together  or 
is  observed  only  as  fila- 
ments in  the  urine. 


Subjective  Symptoms. — 
Pain  absent ;  possibly  sen- 
sation of  tickling  or  of 
"cold,"  occurring  irregu- 
larly and  of  short  dura- 
tion. 

Liabilities. —  Excess  of 
any  kind  much  less  likely 
to  aggravate  symptoms. 

Danger  of  contagion 
slight. 


Chronic  Urethral 
Moisture. 

Objective  Symptoms — Not 
constant  in  the  morning 
nor  after  many  hours'  re- 
tention of  urine.  Consists 
simply  of  a  drop  of  trans- 
parent iluid,  appearing 
especially  on  straining, 
which  can  be  stretched 
between  the  points  of  the 
fingers  from  an  inch  and 
a  half  to  two  inches. 

Subjective  Symptoms. — 
None. 


Liabilities. — Not  affected 
unless  by  extraordinary 
imprudence. 

No  danger  of  contagion. 


Thus  it  will  appear  that,  although  gleet  has  certain  claims  to  be  con- 
sidered as  an  affection  distinct  from  chronic  gonorrhoea,  yet  the  two  have 
no  broad  line  of  distinction  between  them,  and  the  latter  may  gradually 
merge  into  the  former.  Much  in  the  way  of  treatment  is  also  ap[)licable 
to  the  two  affections,  and  I  have  therefore  deferred  speaking  of  certain 
means  adapted  to  chronic  gonorrhoea  until  tlie  present  chapter. 

Gleet  generally  follows  without  interval  an  attack  of  gonorrhoea,  as  a 
consequence  of  the  neglect  or  unsuccessful  treatment  of  the  latter.  In 
many  cases,  however,  gonorrha-a  runs  tlirough  its  successive  stages  and  is 
ajjparently  cured  ;  then  after  an  interval  of  several  weeks  or  even  months 
the  patient  returns  with  the  report  that  he  has  recently  noticed  in  the 
morniug  on  rising  that  the  lips  of  his  meatus  adhere  together,  and,  on  sep- 
arating them,  that  the  urethra  contains  a  small  amount  of  matter  ;  he  suf- 
fers no  pain  or  inconvenience,  but  is  still  anxious  about  his  discharge  and 
desires  to  be  free  from  it.  In  such  instances,  it  is  probable  that  the  cure 
of  the  preceding  urethritis  was  only  apparent,  and  that  a  slight  degree  of 
inflammation  was  left  in  the  deeper  portions  of  the  canal,  not  manifesting 


80  ■  GLEET. 

itself  externally  until  aggravated  by  some  exciting  cause,  as  coitus,  alco- 
holic stimulants,  latigue,  etc.  Or,  again,  it  is  not  improbable  that  there  is 
a  stricture  of  the  urethra,  which  is  the  most  frequent  cause  of  the  continu- 
ance of  a  gleety  discharge  following  an  acute  attack  of  gonorrhoea.  Other 
organic  changes  may  exist  within  the  canal  and  be  productive  of  gleet,  as 
a  granular  condition  of  the  mucous  membrane,  vegetations  similar  to  those 
met  with  upon  the  internal  surface  of  the  prepuce,  and,  in  rare  instances, 
polypoid  growths. 

Idiopathic  gleet,  or  gleet  not  preceded  by  acute  urethritis,  may  be  de- 
pendent upon  various  affections  of  the  prostate,  and  especially  upon  the 
hypertrophy  of  this  gland  so  common  in  old  men.  It  may  also  arise  from 
disorder  of  the  digestive  function,  and  from  disease  of  the  bladder  or  kid- 
neys, whereby  the  urine  is  rendered  abnormally  irritating. 

Gleet  is  often  maintained  by  a  state  of  general  debility,  or  by  a  strumous, 
rheumatic,  or  gouty  diathesis.  That  general  debility  is  a  fruitful  source 
of  the  persistence  of  gleet,  is  evident  from  the  frequency  of  this  disease  in 
])ersons  of  broken-down  constitutions,  and  from  the  beneficial  influence  of 
tonics  and  general  hygienic  measures  in  its  treatment.  Again,  gleet  is 
peculiarly  frequent  and  obstinate  in  persons  of  a  strumous  diathesis  who 
are  subject  to  chronic  inflammation  of  other  mucous  membranes,  and  under 
such  circumstances  it  is  benefited  by  the  administration  of  anti-strumous 
remedies.  The  influence  of  rheumatism  and  gout  in  the  production  of  dis- 
charges from  the  urethra  has  already  been  mentioned  in  connection  with 
gonorrhoea. 

Symptoms In  many  cases  of  gleet,  the  discharge  is  the  only  symp- 
tom. There  is,  as  before  mentioned,  an  entire  absence  of  pain  in  the 
part,  of  redness  and  tumefaction  of  the  lips  of  the  meatus,  and  of  scalding 
in  passing  water.  In  some  instances,  however,  the  patient  expei'iences  a 
feeling  of  uneasiness  in  the  penis  or  perinfeum,  or  an  itching  about  the 
glans  or  in  the  deeper  portions  of  the  canal,  which  may  either  be  constant 
or  attendant  only  upon  the  passage  of  the  urine.  Again,  at  the  first  act  of 
micturition  in  the  morning,  the  obstruction  offered  to  the  exit  of  the  stream 
by  the  matter  which  has  dried  around  the  meatus  and  glued  its  lips  to- 
gether often  gives  rise  to  forcible  distention  of  the  canal,  and  a  sharp 
momentary  pain  in  the  urethra,  wliich  may  be  avoided  by  previously  sep- 
arating the  lips  of  the  orifice. 

The  discharge  in  gleet  varies  in  its  character,  quantity,  and  in  the  time 
of  its  appearance.  In  some  cases  it  is  evidently  purulent,  especially  when 
the  gleet  has  followed  a  recent  attack  of  gonorrhoea.  In  other  instances, 
it  is  perfectly  transi)arent,  and,  examined  under  the  microscope,  is  found 
to  consist  of  a  clear  fluid,  containing  epitlielial  cells  and  free  nuclei,  either 
with  or  without  a  few  pus-globules.  Again,  coagulated  masses,  like  the 
white  of  an  egg,  are  sometimes  forced  from  the  canal.  In  some  cases,  the 
discharge  is  constant,  and  sufficiently  copious  to  stain  the  linen  ;  but  in 
the  majority  it  is  perceptible  only  in  the  morning  on  rising.     When  de- 


PATHOLOGY.  81 

pendent  upon  inflammation  of  the  deeper  portions  of  the  canal,  or  of  the 
prostate,  it  may  only  appear  during  the  efforts  of  the  patient  at  stool,  or 
be  mingled  with  the  last  drops  of  urine  in  micturition.  The  small  amount 
of  the  discharge  in  most  cases  of  gleet,  and  the  frequency  of  this  disease 
among  soldiers,  has  given  rise  to  the  name  "goutte  militaire,"  employed 
by  the  French. 

Hunter,  in  his  work  on  Venereal,  states  that  "a  gleet  is  perfectly  inno- 
cent with  respect  to  infection,"  and  that  in  the  relapses  which  sometimes 
occur,  "the  virus,"  in  his  opinion,  "does  not  return."  This  statement, 
although  often  refuted,  still  iinds  place  in  many  elementary  works,  which 
are  in  the  hands  of  medical  students.  A  doctrine  more  dangerous  to  the 
peace  of  families  could  scarcr^iy  be  promulgated.  It  is,  indeed,  true,  that 
men  are  occasionally  met  witii  who  have  for  years  suffered  from  gleet,  and 
who  have  yet  had  frequent  connection  Avith  their  wives  with  impunity,  but 
where  contagion  ceases  and  immunity  begins/  no  one  can  tell ;  and  even 
if  we  were  able  to  pronounce  a  discharge  of  a  certain  degree  of  purity 
innocuous,  we  could  not  foresee  the  effect  upon  it  of  a  few  hours'  sexual 
indulgence.  It  may  at  the  pi'esent  moment  be  wholly  mucous,  and  entirely 
innocent  of  contagious  properties,  and  yet  a  short  time  hence  be  purulent, 
and  in  the  highest  degree  dangerous.  The  fact  is,  no  one  can  pronounce 
sexual  congress  safe,  so  long  as  a  urethral  discharge  exists,  and  in  replying 
to  the  frequent  questions  of  patients  on  this  point,  the  surgeon  should  not 
only  avoid  incurring  the  responsibility  of  allowing  it,  but  do  all  in  his 
power  to  dissuade  from  it. 

Pathology The  pathological  changes  in  gleet  are  the  same  as  those 

met  with  in  chronic  inflammation  of  other  mucous  surfaces,  as  the  con- 
junctiva, tear  passages,  the  external  meatus  auditorius,  etc. 
This  fact  had  already  been  regarded  as  probable  from  a 
few  post-mortem  examinations  made  by  Rokitansky,^  Mr. 
Thompson,^  and  others,  but  has  been  placed  in  a  much 
clearer  light  since  the  introduction  of  the  endoscope. 

The  changes  revealed  by  this  instrument  as  occurring 
in  chronic  gonorrhoea  have  been  described  in  the  previous 
chapter,  and  the  same  may  be  found  in  gleet.  More  es{)e- 
cially  some  remains  of  a  granulating  surface,  a  slight 
stricture,  or  recurrent  attacks  of  herpes  within  the  canal, 
will  account  for  the  persistency  of  a  discharge.  The 
presence  of  polypoid  growths  is  not  common,  but  they  are 
occasionally  met  with,  and  the  accompanying  wood-cut 
represents  one,  of  the  actual  size,  whicli  was  removed  by 

'  "  •'        I- rethral  polvpus. 

Griinfeld  through  the  tube  of  the  endoscope.     The  con- 
tinuance of  the  inflammation  within  the  ducts  opening  into  the  urethra, 
after  the  canal  itself  is  free  from  disease,  will  also  explain  many  cases  of 

'   Pathologicc-),!  Anatomy,  Sydenliaiii  Society's  Translation,  vol.  ii,  p.  233. 
^  Stricture  of  the  Urethra,  2d  etl.,  lS58,  p.  74. 
6 


82 


GLEET. 


gleet.  The  lacuna  magna  (Fig.  8)  upon  the  superior  wall  of  the  fossa 
navicularis  is  peculiarly  exposed  from  its  situation  to  participate  in  tlie  in- 
flammation of  gonorrlioia,  and  its  internal  surface  is  not  readily  accessible 
to  injections.  Dr.  Phillips^  states  that  he  has  succeeded  in  curing  four 
obstinate  cases  of  gleet  by  introducing  a  director  along  the  upper  surface 
of  the  urethra  until  its  extremity  entered  the  lacuna  magna,  and  slitting 
up  the  wall  of  the  follicle  with  a  narrow  bistoury. 


TREATMENT Ricord   used  to 

"  Gentlemen,  if  I  am  to  go  to 


say  to  the  students  at  his  lectui-es — 
-  well,  the  bad  place,  I  know  what  my 
punishment  will  be.  I  shall  have  a  lot  of 
fellows  with  the  gleet  standing  round  me,  with 
their  lamentations,  their  importunities,  and 
their  prayers  to  me  to  make  them  well."  This 
mauiKiis  mot  but  faintly  indicates  the  annoy- 
ance which  a  case  of  gleet  often  gives  both  to 
patient  and  surgeon ! 

The  treatment  of  gleet  should  be  addressed 
to  the  general  condition  of  the  patient  as  well 
as  to  the  local  disease.  It  may  be  laid  down 
as  a  rule  to  which  there  are  but  few  exceptions, 
that  in  gleet  the  tone  of  the  general  health  is 
more  or  less  reduced.  Not  that  all  patients 
with  gleet  are  necessarily  weak  and  emaciated ; 
on  the  contrary,  many  appear  to  be  robust  and 
hearty;  but  it  is  almost  always  the  case  that 
they  are  not  capable  of  the  same  amount  ©f 
exertion  as  formerly;  they  are  sensible  that 
they  have  lost  a  portion  of  their  animal  vigor ; 
and  the  benefit  of  general  hygienic  measures 
and  tonics  in  their  treatment  is  unmistakable. 
The  diet  should  be  plain  but  substantial,  con- 
sisting of  fresh  meat,  vegetables,  eggs,  etc.,  to  the  exclusion  of  salt  meats, 
cheese,  and  highly-seasoned  articles  ;  and  secretion  from  the  skin  should 
be  promoted  by  means  of  frequent  sponging  or  bathing.  "With  regard  to 
exercise,  although  a  long  walk  or  ride,  especially  when  carried  to  fotigue, 

»  This  experienco  of  Dr.  Phillips  was  given  in  the  first  edition  of  this  work,  1861, 
p.  87.  The  "Dr.  riiillips"  referred  to  was  Dr.  Clias.  Phillips,  Traits  des  mal.  des 
voies  urinaires,  Paris,  18(iO,  p.  34.  With  singular  coincidence  of  the  name  of  Phillips 
and  the  number  of  reported  cases  (4),  Prof.  Otis  (Stricture  of  the  Male  Urethra, 
N.  Y.,  1878,  p.  9)  says:  "Dr.  Benjamin  Phillips,  in  his  treatise  on  'Diseases  of 
the  Urethra,'  states  that  he  has  found  the  continuance  of  a  chronic  gonorrhoea  to 
depend  upon  the  engagement  of  the  lacutia  marjna  in  the  disease,  and  cites  four 
cases  of  cure  by  slitting  up  the  inferior  wall  of  that  sulcus  on  a  director." 

Mr.  Milton,  "On  Gonorrhea,"  4th  ed.,  p.  312,  says  he  has  "sought  in  vain  for 
the  work  referred  to  by  Dr.  Otis,  of  which  no  date  nor  page  is  given,"  and  my  own 
efforts  have  been  equally  unsuccessful.  Further  information  of  Dr.  Benjamin 
Phillips  and  his  work  on  "Diseases  of  the  Urethra"  is  evidently  called  for  ! 


A.  Superior  surface  of  urethra. 
B.  Fossa  navicularis.  G.  Probe 
inserted  in  D,  the  lacuna  magna. 
(After  Gm'-rin,  Elements  de  chir. 
ojieratoire,  185.5,  p.  526.) 


TREATMENT.  83 

will  be  found  to  aggravate  the  discharge,  yet  when  commenced  with  mode- 
ration, and  gradually  and  steadily  increased  in  proportion  to  the  strength, 
it  is  found  to  be  highly  beneficial.  Healthy  exercise  of  the  mind  is  no  less 
important  than  that  of  the  body,  and  the  attention  of  the  patient  should  be 
distracted  as  much  as  possible  from  his  disease,  and  all  books  and  associa- 
tions calculated  to  excite  the  passions  be  avoided.  The  bowels  should  be 
opened  daily,  if  possible  by  selecting  such  articles  of  food  as  are  laxative, 
and  by  regularity  in  the  hour  of  going  to  the  closet,  or  if  required,  by  the 
administration  of  medicine.  One  of  the  following  pills,  taken  at  bedtime, 
will  usually  insure  a  free  stool  in  the  morning. 

I^.    Strychnise  gr.  ss 103 

Pil.  Colocvntli.  Comp.  3ss      ....       2| 
M. 
Divide  into  thirty  pills. 

In  the  tincture  of  the  chloride  of  iron,  we  have  a  most  valuable  combi- 
nation of  a  tonic  and  an  astringent ;  Avhich,  in  most  cases  of  disease  of  the 
generative  organs  in  the  male  and  female,  is  unequalled  by  any  of  the  more 
modern  and  elegant  preparations  of  this  mineral.  It  may  be  given  in  doses 
of  from  five  to  twenty  drops,  largely  diluted  with  water,  three  times  a  day, 
directly  after  meals.  If  the  dose  be  properly  graduated,  it  less  frequently 
excites  headache  in  the  male  than  the  female;  should  this  unpleasant 
symptom  occur,  iron  reduced  by  hydrogen  may  be  substituted  for  it,  in 
doses  of  three  grains,  three  times  a  day.  "Where  the  constitutional  debility 
is  marked,  the  union  of  quinine  with  iron  may  be  desii'able,  as  in  the  fol- 
lowing : — 

I^.    Ferri  et  Quiniae  Citratis  3J-iiJ     •     •     •       4 — 12 

Aqu?e  §1 30 

Syrupi  Limonis  §iij 120] 

M. 
A  teaspoonful  (5.00)  after  each  meal. 

^..    Tincturse  Cantharidis  5j 4 

Quiniae  Sulpliatis  5"^s 2 

Tincturse  Ferri  Cliloridi  5ij     ....  8 

Acidi  Sulpliurici  diluti  gtt.  xxx       .     .  2 

Aquae  destillatje  §viij 250 

M. 
One  ounce  (30.00)  three  times  a  day.  (Cliilds.)  . 

Other  salts  of  iron,  as  the  tartrate  of  iron  and  potassa,  or  the  pyrophos- 
phate of  iron,  may  be  substituted  for  the  citrate,  in  the  first  of  the  above 
prescriptions. 

Witli  patients  of  a  strumous  diathesis,  cod-liver  oil,  the  syrup  of  tlie 
phosphates,  or  Blancard's  pills  of  iodide  of  iron,  may  often  be  used  with 
advantage.  I  have  found  that  the  iodide  of  potassium  has  a  tendency  to 
increase  the  discharge  from  the  urethra,  as  it  often  does  the  secretion  from 
other  mucous  membranes,  and  I  do  not  therefore  administer  it.  Tliis  eHect 
of  the  iodide  may  frequently  be  observed,  when  we  are  giving  it  for  tertiary 
S3q)hilis  to  patients,  who,  at  the  same  time,  are  affected  with  gleet. 

From  what  has  already  been  said  of  copaiba  and  cubebs,  it  is  evident 
that  but  little  good  can  be  expected  from  their  administration  in  cases  of 


84  GLEET. 

chronic  urethral  discharge.  Moreover,  most  patients  whose  disease  has 
arrived  at  this  stage,  have  already  taken  them  ad  nauseam  for  the  pre- 
ceding gonorrhoea ;  hence,  we  are  rarely  called  upon  to  administer  them  in 
pure  gleet.  In  those  cases,  however,  in  which  the  gleet  has  relapsed  into 
a  clap,  they  may  be  given  with  benefit,  especially  when  combined  with  a 
tonic,  as  in  the  drag^es  of  copaiba,  cubebs,  and  citrate  of  iron  ;  in  Meot's 
pills,  the  formula  for  which  has  already  been  given;  and  as  in  the  following 
prescription  : — 

I^.     Copaibae  §ss 151 

Tinctiirse  Caiitharidis  ,^ss      .     .     .  ^  .     .     15 
Tincture  Ferri  Chloridi  §j 30 1 

M. 
Dose. — Thirty  drops  (2.00)  three  times  a  day. 

The  reader  will  observe  that  the  tincture  of  cantharides  is  an  ingredient 
of  several  of  the  above  prescriptions.  Experience  has  shown  that  this 
drug  exerts  a  decidedly  curative  action  in  many  cases  of  gleet,  and  in 
gonorrhoea  also,  in  the  chronic  stage.  It  is  a  favorite  remedy  with  the 
homoeopaths,  in  doses  of  a  fraction  of  a  drop  of  the  tincture  every  few  hours, 
in  the  acute  stage  of  clap,  and  is  considered  by  them  to  be  indicated  by 
scalding  in  micturition,  chordee,  and  a  greenish  or  bloody  discharge.  I 
have  used  it,  however,  only  in  the  chronic  stage.  The  tincture  may  be 
given  in  doses  of  three  or  five  drops  three  times  a  day,  or  it  may  be  com- 
bined with  iron,  as  follows  : — 

I^.     Tinctur?e  Cantliaridis  5ij 8j 

Tincturse  Ferri  Chloridi  gvj      ....       24| 
M. 
Ten  drops  (0.65)  in  water,  three  times  a  day. 

In  some  cases  of  gleet  there  is  considerable  irritability  of  the  neck  of  the 
bladder,  as  shown  by  a  frequent  desire  to  pass  the  urine  and  unpleasant 
sensations  in  the  perinasum.  In  these  cases  benefit  will  be  derived  from 
the  administration  of  the  salts  of  potash,  combined  with  hyoscyamus,  or 
from  the  oil  of  yellow  sandal  wood  or  copaiba. 

Bougies In  all  cases  of  gleet,  the  uretlira  should  be  carefully  examined 

with  proper  instruments,  in  order  to  detect  the  presence  of  stricture  ;  and 
if  the  slightest  contraction  be  discovered,  it  should  at  once  receive  appro- 
))riate  treatment,  since  upon  its  removal  Avill  probably  depend  the  cure  of 
the  discharge. 

Of  late  years,  my  friend.  Dr.  F.  N.  Otis,  has  especially  insisted  upon  the 
dependence  of  gleet  on  a  narrow  meatus  or  on  a  slight  stricture,  "  stricture 
of  large  caliber,"  within  the  canal ;  indeed,  excluding  cases  of  polypoid 
growths  and  inflammation  of  urethral  sinuses,  he  believes  that  gleet  is 
always  symptomatic  of  stricture,  as  the  following  quotations  from  his  writ- 
ings will  show  : 

"  Chronic  urethral  discharge  means  stricture. 

"  "When  there  is  discharge,  there  will,  in  every  case,  be  found,  if  the 
examination  is  efficiently  made,  a  iceU-dcJined  and  unmistakable  point  of 
stricture. 


BOUGIES.  85 

"  The  complete  division  of  stricture  has,  in  my  experience,  resulted  uni- 
formly in  its  complete  disappearance  witliin  a  period  varying  from  three 
months  to  one  year,  and  the  cure  of  gleet  has,  as  a  rule,  followed  the  com- 
jilete  divisio7i  of  stricture  ivithin  a  period  varying  from  tioentyfour  hours 
to  four  weeks  after  the  final  operation."^ 

While  believing  with  Dr.  Otis  that  every  undoubted  stricture  of  the 
urethra  should  be  removed,  and  that  without  its  removal  no  case  of  gleet 
can  be  per7nanently  cured,  I  have  yet  seen  quite  a  number  of  cases  in 
which  after  the  most  thorough  operation  for  the  stricture  and  when  no 
traces  of  the  same  remained,  the  discharge  still  continued  for  months  and 
even  years ;  I  cannot,  therefore,  agree  with  him,  that  always  "  chronic 
urethral  discharge  means  stricture,"  or  that  the  removal  of  all  strictures 
invariably  cures  gleet.  The  removal  of  the  stricture  is  in  all  cases  required, 
but  may  not  be  sufficient  to  stop  the  discharge. 

Dr.  Otis  has  done  great  service  by  calling  attention  to  the  influence  of 
strictures  of  large  caliber,  both  immediate  and  reflex,  which  had  been 
generally  ignored,  and  his  urethrometer  to  determine  the  size  of  the  urethra 
and  the  presence  of  coarctations,  is  a  great  advance  in  our  means  of  diag- 
)iosis.  For  a  full  account  of  this  instrument,  as  well  as  of  his  "  dilating 
urethrotome,"  the  very  best  devised  for  division  of  strictures  of  large  cali- 
ber, the  reader  is  referred  to  the  chapter  on  stricture. 

Acorn-  or  olive-pointed  sounds,  first  proposed  by  Charles  Bell,  are 
also  essential  for  the  diagnosis  of  slight  strictures.  As  frequently  made, 
the  shaft  is  unnecessarily  long,  for  with  a  straight  stem  they  are  only 
adapted  to  detect  strictures  in  the  straight  portion  of  the  canal.  If  you 
want  to  explore  the  urethra  beyond  the  bulbous  portion,  use  a  flexible 
bougie  a  boule,  or,  better  still,  a  stiff  acorn-pointed  steel  sound  bent  in  the 
proper  curve.  P]ven  then  look  out  that  you  do  not  mistake  the  con- 
traction at  the  triangular  ligament  or  at  the  neck  of  the  bladder  for  a 
stricture.  This  mistake  has  often  been  made  not  only  by  novices,  but  by 
those  who  ought  to  have  known  better. 

We  have  already  remarked  that  the  tendency  of  gonorrhoea  in  its  last 
stages  is  to  limit  itself  to  cei'tain  points  of  the  canal,  and  these  points  may 
often  be  discovered  on  passing  an  olive-pointed  sound.  If  we  find  on 
repeated  introductions  tliat  the  patient  always  complains  of  sensitiveness 
at  the  same  spot,  we  have  reason  to  believe  tiiat  tliis  is  the  seat  of  abnor- 
mal changes.  If  granulations  exist,  there  may  be  a  flow  of  a  few  drops 
of  blood  or  the  bulb  on  withdrawal  be  found  smeared  with  the  same.  Pus 
may  also  be  withdrawn  in  the  same  manner  from  the  urethral  pouch  just 
behind  a  stricture,  even  when  the  urethra  might  be  su[)[)Osed  to  have  been 
cleansed  by  tlie  passage  of  urine  a  short  time  previous. 

The  frequent  passage  and  retention  of  bougies  is  one  of  the  best  means 
known  for  the  treatment  of  gleet,  even  when  no  stricture  can  be  discovered. 
The  manner  in  which  bougies  eflect  a  cure  of  chronic  urethral  discliarges 

'  Am.  Clinical  Lectures,  edited  by  Seguin,  vol.  i,  no.  x.  The  italics  are  in  tlie 
orisinal. 


86  GLEET. 

is  somewhat  obscure,  but  is  probably  to  be  explained  on  the  ground  that 
they  distend  the  canal,  expose  lacunar  in  which  matter  would  otherwise 
lodge,  and  separate  for  a  time  the  diseased  surfaces  :  or,  again,  they  may 
serve  to  stimulate  the  vessels  of  the  part,  and  thus  change  their  action. 

Bougies  tapering  towards  the  extremity  and  terminating  in  an  olive- 
shaped  point,  are  well  adapted  for  the  purpose.  They  are  introduced 
easily  and  with  little  inconvenience  to  the  patient,  and  the  contraction 
near  their  point  facilitates  the  introduction  of  medicated  ointments  into 
the  deeper  portions  of  the  canal.  The  instrument  should  be  large  enough 
fully  to  distend  the  canal  but  not  to  stretch  it,  and  is  best  smeared  with 
vaseline.  The  bladder  should  previously  be  emptied  and  the  patient  placed 
in  the  recumbent  posture.  However  gently  it  may  be  introduced,  the 
first  passage  of  a  bougie  usually  excites  a  more  or  less  disagreeable  sensa- 
tion, which  sometimes  gives  rise  to  syncope,  and  which  generally  renders 
it  advisable  to  withdraw  the  instrument  in  a  few  minutes  ;  but  after  two  or 
three  insertions  it  ceases  to  give  annoyance,  and  may  be  retained  for  half 
an  hour  or  an  hour. 

It  sometimes  happens  that  the  bougie  aggravates  the  discharge,  and  re- 
vives the  acute  inflammation  which  has  for  a  time  disappeared.  In  such 
cases  it  is  best  to  suspend  the  treatment  and  resort  to  injections,  which 
w^ill  often  effect  a  permanent  cure.  This  aggravation  of  the  symptoms 
however,  according  to  my  experience,  takes  place  in  a  minority  of  cases 
only. 

With  this  exception,  the  passage  of  the  bougie  may  be  repeated  every 
second  or  third  day  at  first,  and  afterwards  every  day,  or  in  some  instances 
as  often  as  twice  a  day. 

Bougies  may  be  medicated  in  various  ways.  Calomel  rubbed  up  with 
sufficient  glycerine  or  oil  to  cover  it,  forms  a  very  cleanly  and  excellent 
mixture  with  which  to  anoint  the  bougie,  and  I  think  materially  assists 
the  curative  action.  Mercurial  ointment  may  also  be  used  either  alone 
or  combined  with  extract  of  belladonna,  the  latter  being  added  in  case  the 
urethra  is  irritable. 

I^.     Unguenti  Hydrargyrl  §ss 15] 

Extract!  Belladoiinse  5ss 2| 

M. 

For  the  purpose  of  stimulating  the  mucous  membrane,  we  may  employ 
the  diluted  ointment  of  red  oxide  of  mercury,  or  an  ointment  containing 
a  few  grains  of  nitrate  of  silver,  but  such  applications  should  not  be  con- 
tinued for  any  length  of  time,  lest  they  keep  up  tlie  discharge. 

^.     Ung.  Hydrarg.  Oxidi  Riiliri  5.i    .     .     •       41 

Adipis  ^iij 12| 

M. 

^^.     Argenti  Nitratis  gr.  v-x   .     .         130     —     [60 

Adipis  §j SOJ 

M. 

In  old  cases  of  gleet  I  have  used  the  following  mixture  with  very  satis- 
factory results.     A  full-sized  sound  should  be  thoroughly  smeared  with  the 


THE    ENDOSCOPE. 


87 


tenacious  mass,  then  oiled  and  be  passed  as  far  as  the  membranous  portion 
of  the  urethra,  and  allowed  to  remain  for  three  minutes.  The  first  effect 
is  to  increase  the  discharge,  which,  however,  subsides  in  the  course  of  a 
few  days  to  a  less  quantity  than  before  the  application,  when  the  process 
is  to  be  repeated  at  intervals  until  a  cure  is  effected. 

IJl.     Cupri  Sulphatis  ^iss 6] 

Cerse  Albse  ^j 30 

Adipis  5iss •     .     .     .  61 

M. 

Any  ordinary  sound  will  answer  for  the  application,  although  one  may 
be  made  especially  adapted  for  the  purpose  with  a  number  of  cup-shaped 
depressions  to  hold  the  ointment,  as  represented  in  Fig.  9. 

Fie:.  9. 


Cupped  sound. 

Another  most  excellent  application  is  a  mixture  of  tannin  and  glycerine 
in  such  proportions  that,  when  cold,  it  will  form  a  solid  mass.  The  cups 
are  filled  with  the  mass,  which  is  liquefied  by  the  heat  of  the  body. 

T/te  Endoscope. — It  is  a  good  rule  to  follow  in  learning  the  use  of  the 
Endoscope,  as  it  is  of  the  microscope,  for  the  beginner  to  commence  with 
the  simplest  instruments  and  afterwards  add  to  his  stock  as  his  wants  and 
his  own  experience  dictate.     All  that  is  wanted  for  the  examination  of  the 

Fiff.  10. 


The  upper  figure  represents  the  metalUc  endoscopic  tube  which  is  blackened  on  the  inside; 
the  lower  figure  its  conductor  and  handle  to  facilitate  its  introduction,  made  of  hard  rubber. 

urethra  is  a  number  of  straight  urethral  tubes  adapted  to  different  sizes  of 
the  canal,  and  the  necessary  means  of  illumination.  The  tubes  proposed 
by  many  ilifferent  authors  are  all  about  tlie  same  and  e(iually  serviceable. 
Fig.  10  represents  those  of  Grlinfeld,  one  of  the  latest  and  most  advanced 
writers  on  endoscopy.  Cuts  of  the  desirable  accessory  instruments,  a 
swab-holder  for  removing  blood  and  mucus,  a  pencil  for  the  api)lication  of 
caustics  or  astringents,  a  j)owder-blower  for  the  same  purpose,  forcei)S  and 
scissors  for  the  removal  of  urethral  polypi,  a  larger  bent  tube  with  a  glass 


88 


GLEET. 


window  at  the  bend  for  the  examination  of  the  deeper  parts  of  the  canal 
and  the  bladder,  are  also  given.  These  are  enough  and  more  than 
enough  for  the  requirements  of  any  one  but  a  specialist. 


Fis.  11. 


FORD 

C.H.&C2 


Swab-hulder  for  removing  blood  and  urethral  discharges. 
Fig.  12. 


Blower  for  medkatod  powders,  and  pencil  for  application  of  caustic  and  astringent  solutions. 

Fig.  1.3. 


Scissors  for  removal  of  polypi. 


Fig.  14. 


FORD 
C,  H.  X  C2 
Forceps  for  removal  of  polypi. 


^ 


T^nr  illumination,  sunlight,  when  obtainable  better  than  artificial  light, 
is  thrown  in  through  the  tube  by  means  of  the  ordinary  frontal  mirror. 
In  the  absence  of  sunlight,  an  argand  burner  or  Tobold's  condenser.  Such 
instruments  and  such  mode  of  illumination  are  all  that  are  in  general  use 
at  the  present  day.  They  are  indeed  in  some  respects  superior  to  the  older 
and  more  cumbrous  ones,  since  they  enable  the  observer  to  control  the 
direction  of  the  light  and  detect  lights  and  shadows  marking  not  only 
pathological  changes  but  the  openings  of  the  ducts  of  urethral  follicles, 
observed  in  this  way  for  the  first  time  by  Griinfeld,  whose  valuable  papers 
are  recommended  to  the  reader.^ 

Desormeaux's  original  instrument,  represented  in  Fig.  15,  is  expensive 

'  Der  Harnrohren-Spiegel,  seine  Anweiiduiig  ;  Wiener  Klinik,  Felirnar-Milrz, 
1877.  See  also  Wiener  med.  Presse,  No.  11  and  12,  1874;  Die  Endoscopie  bei 
Strictnren  der  Urethra,  Wiener  med.  Wochensclirift,  No.  39,  Sej^t.  2.5,  1875  ;  Auto- 
endoscopie  der  Urethra,  Wiener  med.  Ztg.  No.  36,  1875. 


THE    ENDOSCOPE. 


89 


and  not  easily  handled.     The  same  may  be  said  of  Cruise's,  which  affords 
rather  a  better  light. 

Fi-.  15. 


D^sormeaux's  endoscope.     The  lower  tube,  -nitli  a  glass  window  at  the  commeacement  of 
the  bent  extremity,  is  intended  for  exploration  of  the  bladder. 

In  the  absence  of  sunlight  a  modification  of  Desormeaux's  instrument 
by  Denis  is  excellent,  Fig.  1 G.  It  is  much  cheaper  than  Desormeaux's 
and  handled  more  readily  and  with  less  discomfort  to  the  patient. 


Desormeaux's  endoscope  modified  hy  Denis. 

Mr.  Cruise  uses  as  a  burning  fluid  a  solution  of  camphor  in  kerosene, 
ten  grains  "or  more"  to  the  ounce.  I  use  in  Denis's  instrument  one  part 
of  the  best  sperm-oil  and  six  parts  of  Pratt's  Astral  oil,  which,  by  the  way, 
is  an  excellent  compound  to  burn  in  the  German  students'  lamp. 

Fig.  17  represents  an  endoscope  adapted  to  ordinary  gaslight. 


90 


GLEET, 


Just  as  this  edition  is  going  to  press,  a  new  dilating  urethroscope  has 
been  presented  to  the  profession  by  Auspitz'  (Fig.  18).     The  name  of  its 


Fitr.  17. 


eminent  inventor  is  sufficient  to  lead  us  to  anticipate  from  it  the  advantages 
Avhich  he  claims  it  possesses. 

Success  in  the  use  of  the  endoscope  requires  dexterity  on  the  part  of  the 
surgeon,  which  can  only  be  attained  by  practice.  The  patient's  urethra 
should  also  be  habituated  to  the  use  of  instruments  by  the  passage  of  sounds 
before  an  endoscopic  examination  is  attempted,  and  this  may  require  several 
preliminary  sessions.  The  best  position  to  place  him  in  is  the  horizontal 
with  the  knees  strongly  flexed,  and  the  tube  should  be  introduced  into  the 
membranous  or  prostatic  portion  of  the  canal  before  the  plug  is  withdrawn. 
Other  portions  are  brought  into  view  as  the  tube  is  drawn  out. 

It  will  readily  be  seen  that  for  the  purposes  of  diagnosis,  the  endoscope 

'  Vrtljschr.  f.  Dermat.,  Wien.,  1870,  s.  3. 


INJECTIONS.  91 

proves  itself  to  be  an  invaluable  instrument  in  many  cases,  as,  for  instance, 
in  those  of  urethral  polypi,  or  venereal  ulcers  which  might  otherwise  es- 
cape detection.  It  reveals  also  the  presence  and  the  exact  seat  of  patches 
of  granulations,  spots  of  herpes,  etc.,  and  as  applications  can  be  made 

Fig.  18. 


through  the  tube,  it  enables  us  to  reach  these  parts  directly.  Granulations 
can  be  touched  by  the  solid  nitrate  of  silver,  with  a  solution  of  the  same 
salt,  or  by  any  astringent  in  powder,  as  the  sulphate  of  zinc,  either  pure  or 
diluted.  In  herpes  of  the  canal  Desormeaux  recommends  the  application 
of  the  Oil  of  Cade,  which  looks  a  little  as  if  he  were  governed  by  precon- 
ceived notions  as  to  the  nature  of  the  affection. 

There  is  every  reason  to  believe  that  the  ui-ethroscope,  as  now  improved, 
will  be  found  of  great  value  in  the  treatment  of  chronic  urethral  affections, 
but  hitherto  it  has  not  supplanted  other  means  of  diagnosis  and  treatment, 
and  cases  of  gleet  still  make  their  oft-repeated  visits  at  the  cliniques  of 
Desormeaux  and  other  experts  in  the  use  of  the  endoscope. 

Injections — Injections  have  been  so  fully  discussed  in  the  preceding 
chai)ter,  that  little  remains  at  present  to  be  said  of  their  composition,  or 
the  ordinary  mode  of  their  administration. 

In  gleet  as  in  gonorrhcea,  weak  solutions  of  the  acetate  or  sulphate  of 
zinc  (containing  from  two  to  three  grains  to  the  ounce  of  water)  are  in 
most  instances  to  be  preferred;  and  the  injection  should  be  made  to  per- 
meate the  urethra  as  deeply  as  possible,  in  order  that  it  may  be  applied  to 
the  whole  extent  of  the  affected  surface,  but  care  should  be  taken  not  to 
distend  the  canal  with  too  much  force,  the  sensations  of  the  patient  being 
the  best  indication  when  a  sufRcient  amount  has  been  employed.  So  far 
as  inflammation  of  the  testicle  and  prostate  have  any  connection  with  the 
use  of  injections,  I  believe  they  are  more  frequently  due  to  violent  manipu- 
lation than  to  the  irritant  character  or  strength  of  tlie  solution.  Hence, 
injections  should  always  be  used  with  gentleness,  while  at  the  same  time 
the  canal  should  be  entirely  filled,  that  none  of  the  folds   into  which  the 


92  GLEET. 

urethral  walls  are  naturally  thrown  except  during  the  passage  of  the  urine 
may  escape  coming  in  contact  with  the  astringent  fluid.  With  this  pre- 
caution, a  weak  injection  may  be  employed  after  every  passage  of  the 
urine,  a  degree  of  frequency  which  will  often  prove  successful  when  a  less 
degree  has  failed. 

In  addition  to  the  formuLt  for  injections  given  in  the  chapter  upon  gon- 
orrhoea, the  following  may  be  added : — 

I^.    Hydrargyri  Bicliloridi  gr.  j     .  106 

AqujB  §viij-xij 250j     — 375| 

M. 

^.     Gall?e  ^j 4| 

Aluminis9ij 2  GO 

Aqu£e  §viij 250| 

M. 

I^.     Acidi  Nitrici  gtt.  xvj-xl  .     .         11     —      2\G0 

Aquie  5viij 250| 

M. 

I^.     Liq.  Ferri  Persiilphatis  (Squibb)  5ss  2] 

Aquae  ^vj        180 

M. 

Tiie  strength  of  the  above  solution  may,  in  some  instances,  be  increased. 

Dr.  Lordly,^  of  N.  Y.,  recommends  warm  medicated  injections,  about 
three  pints,  made  daily  by  the  surgeon  himself  by  means  of  a  fountain- 
syringe,  and  a  catheter  introduced  into  the  prostatic  urethra.  The  water 
is  medicated  by  some  astringent,  as  the  sulpho-carbolate  of  zinc,  not  more 
than  three  grains  to  the  ounce.  The  injection  is  to  be  followed  by  the 
insufflation  of  some  astringent  powder. 

Ricord  advises  solutions  containing  iodine  in  scrofulous  subjects,  and, 
altliough  the  injection  of  this  mineral  into  the  urethra  cannot  be  supposed 
to  affect  the  constitutional  diathesis,  yet  it  may  exert  a  beneficial  action 
upon  the  mucous  membrane  as  when  applied  to  the  fauces. 

R.     Tiiict.  lodinii  gtt.  viij 150 

Aquae  §viij 250J 

M.  (Ricord.) 

I^.     Ferri  lodidi  gr.  viij 150 

Aquae  §viij 250|  * 

M.  (Rioord.) 

I  will  here  repeat  a  suggestion  previously  given,  that  the  use  of  any 
medicated  injection,  and  especially  one  containing  insoluble  ingredients, 
will  prevent  even  a  sound  urethra  from  exhibiting  its  normal  dryness. 
Without  due  caution,  therefore,  a  patient  may  go  on  injecting  long  after 
his  disease  is  cured.  Hence,  after  the  discharge  has  for  some  time  been 
reduced  to  a  very  minute  quantity,  and  especially  if  it  appear  to  consist  of 
little  more  than  the  insolu])le  de])osit  of  the  solution,  the  injection  should 
be  omitted  for  a  few  days,  in  order  that  the  exact  condition  of  the  urethra 
may  be  determined  ;  or  again,  it  may  be  administered  only  once  in  the 
twenty-four  hours,  selecting  for  the  purpose  the  early  part  of  the  day,  and 

1  Hospital  Gaz.,  Fob.  15,  1878. 


DEEP    URETHRAL    INJECTIONS. 


93 


J. 


the  appearance  of   tlie  meatus  the  following  morning  Fig.  19. 

will  indicate  what  progress  has  been  made  towards  a 

cure. 

Deep  Urethral  Injections. — In  the  ordinary  method 
of  injecting  the  male  urethra,  it  is  difficult  to  make  the 
fluid  pass  through  the  whole  extent  of  the  canal  into 
the  bladder.  After  a  certain  portion  (about  half  an 
ounce)  of  the  contents  of  the  syringe  has  been  injected, 
the  remainder  escapes  above  the  piston,  or,  however 
tightly  the  glans  may  be  compressed  around  the  point 
of  the  instrument,  flows  from  the  meatus.  The  obstruc- 
tion to  the  entrance  of  the  fluid  is  due  to  the  contraction 
of  muscular  fibres  (the  compressor  urethi'aj  muscle) 
which  surround  the  membranous  portion  and  serve  as 
a  sphincter  to  the  urinary  canal  ;^  and  this  is  the  pos- 
terior limit  of  the  application  of  the  fluid  to  the  ure- 
thral walls  by  the  more  common  method  of  injecting. 
In  order  to  reach  the  deeper  portions  of  the  canal 
which  are  involved  in  many  cases  of  gleet,  it  becomes 
necessary  to  resort  to  injections  through  a  catheter,  or 
by  means  of  the  "  urethral  syringe  with  extra  long  pipe," 
manufactured  by  the  American  Hard  Rubber  Company, 
or  with  Tiemann's  "  universal  syringe,"  which  is  pro- 
vided with  a  catheter  extremity.  ^ 

Mr.  Dick  and  Mr.  Erichsen  recommended  a  catheter 
syringe.  Fig.  19,  for  deep  urethral  injections  ;  the  piston 
consists  of  a  sponge  which  will  absorb  about  a  quarter 
of  a  drachm  of  fluid,  and  this  is  expelled  through  minute 
openings  whenever  the  stylet  is  thrust  down. 

Still  better  for  use  in  the  deeper  parts  of  the  canal  is 
Guyon's  injector  (Fig.  20).  It  consists  simply  of  an  ordi- 
nary bougie  a  bottle,  perforated  by  ?  minute  canal  which 
terminates  near  the  point  in  several  flne  openings.  The 
injection  is  made  through  it  by  means  of  a  common  hy- 
podermic syringe,  provided  with  such  a  nozzle  as  will 
fit  the  bougie.  The  only  objection  to  this  instrument 
is  the  difficulty,  in  some  cases,  in  introducing  a  flexible 
bulbous  bougie  beyond  the  triangular  ligament. 

Tliis  objection  is  obviated  in  my  own  instrument. 
Fig.  21,  which  I  have  found  to  be  well  adapted  for  old 
cases  of  gleet,  sfjermatorrhcea,  etc. 

The  length  of  the  urethra  may  be  measured  by  introducing  a  catheter 
and  marking  the   point   in  contact  with   the  meatus   wlien  the  urine  first 


Dick's  catheter 
syringe. 


•  Seethe  section  on  tlie  Anatomy  of  the  Uretlira  in  the  chapter  on  Stricture. 

2  This  instrument  will  be  found  very  iiseful  in  tlie  treatment  of  venereal  dis- 
eases, for  instance  in  deep  urethral  injections,  in  injections  into  the  nostrils  and 
pharynx,  etc. 


94 


GLEET. 


commences  to  flow  ;  upon  witlulrawing  the  instrument  the  distance  between 
its  eje  and  the  mark   upon  the  stem  will  be   the   measurement  required. 


Fig.  20. 


Guyon's  injector. 


On  introducing  the  catheter-syringe  for  the  purpose  of  injecting  (the  pa- 
tient having  first  passed  his  water),  it  is  an  easy  matter  to  carry  its  point 


Fig.  21. 


Author's  syringe  for  deep  urethral  injections. 

within  half  an  inch  of  the  vesical  neck  without  entering  the  bladder,  when 
the  fluid  may  be  throAvn  in  as  the  instrument  is  slowly  withdrawn.     If  the 

Fig.  22. 

<5t  n?    ^TT  oLvia 


h  h 

K  A  * 


Tieinann's  "  universal  syringe." 

instrument  be  sufficiently  large  to  moderately  distend  the  canal,  none  of 
the  injection  will  escape  from  the  meatus  so  long  as  the  eye  is  in  the  pros- 
tatic or  membranous  portion  of  the  urethra,  since  the  contraction  of  the 
same  muscle  which  prevents  the  entrance  of  fluid  from  without,  also  pre- 
vents its  exit  from  within,  and  obliges  it  to  flow  backwards  towards  the 
bladder ;  hence  we  may,  if  we  choose,  limit  the  application  of  the  injected 
fluid  to  the  deeper  portions  of  the  canal  exclusively,  and  the  pain  excited 
will  be  found  to  be  less  than  when  a  solution  of  the  same  strength  is  thrown 


BLISTERS.  95 

into  the  external  portion,  since  the  urethra,  like  other  mucous  passages,  is 
most  sensitive  near  its  outlet.  The  chief  disagreeable  sensation  following 
an  injection  thus  confined  to  the  portion  of  the  urethra  lying  between  the 
compressor  urethras  muscle  and  the  neck  of  the  bladder,  is  an  urgent  desire 
to  pass  water,  which,  however,  should  be  resisted  as  long  as  possible,  that 
the  fluid  may  have  time  to  act  upon  the  urethral  walls  before  it  is  washed 
away  or  neutralized  by  the  urine.  During  the  succeeding  twenty-four 
hours,  micturition  is  somewhat  more  frequent  than  usual,  but  is  not  par- 
ticularly painful  ;  and  the  discharge  is  often  slightly  increased  for  a  day  or 
two. 

The  efficacy  and  safety  of  these  injections  in  affections  of  the  deeper- 
seated  portions  of  the  uretlira  is  attested  by  MM.  Diday'  and  Bonnet,  of 
Lyons,  Mr.  Langston  Parker,^  of  Birmingham,  and  my  own  experience. 
The  same  formulaj  may  be  employed  that  have  been  recommended  for  in- 
jections by  the  more  common  method,  and  the  application  may  be  repeated 
once  or  twice  a  week. 

Blisters Blisters  were  long  ago  recommended  for  the  cure  of  obstinate 

cases  of  gleet,  but  had  almost  fallen  into  disuse,  when  they  were  revived 
by  Mr.  Milton,  in  his  work  on  the  treatment  of  gonorrhoea.  This  author 
speaks  of  them  in  the  folloAving  terms  :  "  I  have  seen  two  blisters,  with  a 
mild  injection  or  two,  at  once  cure  a  clap  which  had  defied  the  most  ener- 
getic treatment ;  and  as  I  never  found  a  case  which  resisted  blistering  and 
injections  together,  that  was  not  complicated  with  stricture  or  affection  of 
the  testicle,  I  am  slowly  arriving  at  the  conviction,  that  every  case  of  clap 
or  gleet,  hoicever  obstinate,  may,  if  u7icomplicated,  be  cured  by  blistering, 
singly  or  combined.'''^  It  is  to  be  feared,  however,  that  this  remedy  has 
proved  less  successful  in  the  hands  of  other  surgeons  than  in  Mr.  Milton's. 
Recent  writers  who  have  spoken  favorably  of  it  appear  to  have  done  so 
chiefly  on  Mr.  Milton's  authority  ;  others,  as  Mr.  Langston  Parker,  have 
given  their  testimony  decidedly  against  it,  and  in  my  own  practice  it  has 
not  been  attended  with  such  success  as  to  lead  me  to  prefer  it  to  other 
and  less  disagreeable  modes  of  treatment.  Still  it  may  be  worthy  of 
a  trial  in  obstinate  cases  which  have  resisted  the  use  of  bougies  and  injec- 
tions. 

The  manner  of  applying  blisters  to  this  region  is  of  considerable  import- 
ance. The  hair  should  be  shortened  around  the  root  of  the  penis,  and  a 
piece  of  paper  be  wrapped  around  the  organ,  and  cut  in  such  a  manner  as 
to  form  a  pattern  of  its  surface  from  the  pubis  to  within  half  an  inch  of 
its  extremity.    The  blister,  corresponding  in  shape  and  size  to  the  pattern, 

'  Des  injections  circonscrites  a,  la  partie  profonde  de  I'urethre,  de  leur  mode 
d'ex^cution,  et  de  leur  efficacite  curative ;  Annuaire  de  la  syphilis,  annee  1858, 
p.  61.  Diday's  method  of  employing  deep  urethral  injections  has  been  followed 
in  the  above  description. 

*  Syphilitic  diseases,  p.  82.  Air.  Parker  injects  the  fluid  into  the  bladder,  lets 
it  remain  for  a  few  minutes,  and  desires  the  patient  to  force  it  out.  This  ixiethod 
is  not  so  good  as  the  one  above  recommended. 

3  Milton  on  Gonorrhoea.     The  Italics  are  in  the  original. 


96  GLEET. 

should  be  applied  to  the  penis,  and  tied  or  fastened  in  its  place,  that  it 
may  not  slip,  and,  coming  in  contact  with  the  scrotum,  produce  a  trouble- 
some sore.  It  should  not  be  retained  longer  than  two  hours,  during  which 
the  patient  must  remain  quiet.  The  morning  is  the  best  time  for  its  ap- 
plication, since,  if  applied  at  night,  it  is  likely  to  prevent  sleep.  On 
removing  it,  the  surface  is  found  to  be  reddened,  but  not  vesicated,  unless, 
perh.aps,  at  a  few  points  ;  and  the  penis  should  now  be  covered  with  a  rag 
spread  with  simple  cerate,  and  be  ■[protected  from  friction  by  an  external 
layer  of  cotton  wadding. 

On  examining  the  parts  after  a  few  hours,  it  will  be  found  that  numerous 
bullfe  have  formed  on  the  surface,  wliich  at  hrst  appeared  to  be  only  red- 
dened. These  may  be  pricked,  and  the  serum  which  they  contain  evacuated, 
but  the  epidermis  should  be  carefully  preserved.  I  have  sometimes  found 
the  extremity  of  the  prepuce  beyond  the  site  of  the  blister,  puffed  out  Avith 
an  effusion  into  its  cellular  tissue,  which  may  be  left  to  take  care  of  itself, 
or,  if  excessive,  be  evacuated  by  a  few  punctures  with  a  lancet. 

Cantharidal  collodion  is  a  more  convenient  application  than  the  un- 
guentum  lytta?,  but  its  effect  cannot  be  limited  like  that  of  the  latter,  which 
should  therefore  be  preferred.  When  applied  for  a  few  hours  only,  I  can 
confirm  Mr,  Milton's  statement,  that  blisters  do  not  excite  severe  pain,  nor 
produce  a  troublesome  sore.  The  first  effect  of  their  application  is  to  in- 
crease the  urethral  discharge,  which  can  only  be  expected  to  be  benefited 
in  the  course  of  five  or  six  days.  The  blister  may  be  repeated  at  the  end 
of  a  week,  if  any  discharge  still  remain,  Tiie  perinasum  may  be  Vdistered 
in  a  similar  manner,  but  this  will  require  the  patient  to  be  kept  in  bed 
until  the  vesicated  surface  has  healed. 

Separation  of  the  Affected  Surfaces Contact  of  the  diseased  surfaces 

doubtless  assists  in  keeping  up  the  discharge  in  gleet,  as  it  is  well  known 
to  do  in  balanitis.  Hence  it  has  been  proposed,  by  means  of  a  probe  and 
a  gum-elastic  bougie  open  at  the  extremity,  to  introduce  a  strip  of  lint, 
either  dry  or  soaked  in  some  astringent  fluid,  Avithin  the  urethra,  and  thus 
maintain  its  walls  apart,  renewing  tlie  application  after  each  passage  of  the 
urine.  This  method,  in  whicli  I  have  had  no  experience,  has  been  suc- 
cessful in  some  instances,  but  is  very  troublesome  and  inconvenient,  iind 
would  appear  to  be  attended  with  danger  of  the  lint  slipping  entirely  into 
the  urethra,  and  entering  the  bladder,  Civiale  mentions  a  case  in  which 
this  accident  occurred,  but  does  not  give  the  ultimate  result.^  Mr,  Milton^ 
states  that  it  has  happened  to  him  in  several  instances,  and  that  the  lint 
has  always  found  its  way  out,  but  the  danger  of  its  retention  is  too  great 
to  be  incurred.  Separation  of  the  affected  surfjxces  is  partially  effected  by 
certain  forms  of  injections,  as  those  containing  bismuth,  calamine,  and 
other  insoluble  ingredients. 

Finally,  in  obstinate  cases  of  gleet  in  which  the  discharge  appears  to 
come  from  the  anterior  portion  of  the  urethra,  laying  open  the  lacuna 
magna,  as  recommended  by  Dr.  Phillips,  is  worthy  of  a  trial,^ 

'  Maladies  des  organes  genito-urinaires,  vol.  i,  p.  444, 

2  On  Gonorrhrea,  p,  31.  ^  See  page  82, 


CAUSES.  97 


CHAPTER    III. 
BALANITIS. 

Ik  the  prepuce  be  retracted,  a  mucous  surface  of  considerable  extent  is 
exposed,  a  portion  of  which  covers  the  gkins  penis,  and  the  remainder 
consists  of  the  internal  retiection  of  the  prepuce.  This  surface  may  be  the 
seat  of  inflammation,  similar  to  that  wliich  has  been  described  as  affecting 
the  urethra.  If  the  disease  be  confined,  as  it  sometimes  is,  to  the  mem- 
brane covering  the  ghins,  it  should,  strictly  speaking,  be  called  balanitis; 
if  to  the  internal  surface  of  the  prepuce,  posthitis,  and  if  it  involve  both, 
balano-posthitis  ;  all  these  varieties,  however,  for  the  sake  of  convenience, 
are  commonly  included  under  the  one  name,  balanitis.  Gonorrhoea  spuria, 
balano-preputial  gonorrhoea,  and  external  blennorrhagia  are  other  terms  by 
which  it  is  sometimes  known. 

Causes Men  in  wliom  the  prepuce  is  long,  or  who  are  affected  witli 

congenital  phimosis,  are  peculiarly  exposed  to  balanitis,  since  the  mucous 
membrane  covering  the  glans  and  lining  tlie  prepuce,  is  maintained  in  so 
sensitive  a  condition,  from  its  want  of  exposure  to  the  air  and  friction, 
that  inflammation  is  readily  set  up  by  the  least  cause  of  irritation.  Such 
a  cause  is  at  hand  in  the  natural  secretion  which  exudes  from  the  very 
numerous  sebaceous  follicles  that  exist  on  the  internal  surface  of  the  pre- 
puce and  the  furrow  at  the  base  of  the  glans.  If  from  inattention  to,  or 
the  impossibility  of  cleanliness,  as  in  cases  of  phimosis,  this  cheesy  secre- 
tion be  not  frequently  removed,  it  becomes  decomposed  and  is  changed 
into  an  ammoniacal,  foul-smelling,  emulsion-like  fluid,  which  acts  strongly 
as  an  irritant  ujjon  the  delicate  mucous  membrane  with  wliich  it  comes  in 
contaet.  When  phimosis  is  present,  it  will  readily  be  understood  how  this 
fluid,  coming  from  a  small  j)reputial  orifice,  may  be  mistaken  for  urethral 
gonorrhoea.  I  once  had  a  patient  come  to  me  from  the  western  coast  of 
South  America,  simply  to  consult  me  tor  a  supposed  clap,  for  which  he 
had  been  taking  copaiba  and  using  urethral  injections  for  many  months. 
A  careful  examination  showed  that  the  discharge  came  only  from  the 
balano-preputial  fold  in  a  penis  aflected  with  congenital  phimosis,  and  cir- 
cumcision speedily  relieved  him  of  his  trouble.  The  diagnosis  in  such 
cases  is  readily  made,  by  exposing  and  wiping  the  meatus,  and  then  noting 
whether  upon  pressure  the  matter  comes  from  the  urethra  or  from  beneatli 
the  foreskin.  ^Moreover,  the  pain  in  micturition  in  cases  of  urethritis 
extends  along  the  course  of  the  canal,  while  in  balanitis  it  is  confined  to 
the  excoriated  surfaces  of  the  extremity  of  the  penis. 
7    . 


98  BALANITIS. 

It  will  be  evident  that  the  stagnation  and  decomposition  of  any  secre- 
tion, other  than  that  just  nientiontMl,  may  have  the  same  eii'ect.  Thus  the 
purulent  discharge  from  chancroids  situated  on  or  near  the  glans,  the  more 
or  less  watery  secretion  from  a  true  chancre,  mucous  patches  or  other 
secondary  lesion,  the  acrid  exudation  from  vegetations,  a  gonorrlioeal  dis- 
charge gaining  entrance  from  the  meatus, — all  these  are  fr(M]uently  the 
cause  of  balanitis.  The  pressure  exercised  by  a  mass  of  vegetations  or  by 
the  exuberant  development  of  the  indurated  base  of  a  chancre  are  also 
worthy  of  mention. 

Thus  far  we  have  said  nothing  about  contagion  as  a  cause  of  balanitis. 
If  this  were  a  frequent  cause,  the  inimber  of  cases  of  this  atlection  would 
be  even  greater  than  those  of  gonorrhoea,  considering  how  much  more  than 
the  urethra  the  glans  penis  is  exposed  in  sexual  intercourse,  whereas  the 
contrary  is  the  fact,  Sigmund  reckoning  one  case  of  balanitis  to  seventeen 
of  gonorrhoea,  and  Fournier  one  to  twenty-four.  Still  to  this  cause — con- 
tagion— some  instances  of  inflammation  of  the  balano-preputial  fold  may 
doubtless  be  ascribed.  Benjamin  Bell  relates  a  story  of  two  young  men, 
each  of  whom  introduced  beneath  his  prepuce  a  pledget  of  lint  soaked  in 
gonorrheal  matter  and  kept  it  in  place  for  twenty-four  hours.  This  was 
followed  in  one  of  them  by  a  very  severe  attack  of  balanitis  attended  by 
paraphimosis.  The  other  had  a  slight  external  intiammation,  but,  the 
matter  having  entered  the  urethra,  he  was  attacked  on  the  second  day  by 
a  violent  urethritis. 

To  tlie  above  causes  of  balanitis  we  may  add  excessive  coitus,  masturba- 
tion, and  leucorrhoeal  discharges  in  women  with  whom  the  sexual  act  has 
been  accomplished. 

It  appears  from  the  above  that  balanitis  in  the  great  majority  of  cases 
is  not  due  to  contagion  and  is  not,  strictly  speaking,  a  venereal  disease; 
according  to  Fournier's  statistics  it  is  venereal  in  only  one-fifth  of  the 
cases  met  Avith. 

Symptoms In  its  mildest  form  lialanitis  is  a  very  trivial  affair.     The 

patient  complains  of  tenderness  and  an  itching  or  tickling  sensation  at 
the  head  of  the  penis,  and  perliaps  scalding  during  micturition  if  the  urine 
comes  in  contact  with  the  inflamed  surface.  On  examination  we  find  the 
glans  sensitive  to  pressure,  reddened,  smeared  with  a  thin,  whitish  or 
slightly  yellowish,  offensive  fluid,  and  perhaps  here  and  there  deprived  of 
its  epithelium  in  patches. 

In  a  more  advanced  stage  the.  glans  api)ears  to  be  swollen,  its  redness  is 
intensified,  the  prepuce  is  somewhat  tumefied,  the  discharge  is  more  copi- 
ous and  purulent,  the  parts  more  painful  and  sensitive  on  contact  with  the 
clothes.  The  patches  denuded  of  epithelium  are  now  more  marked,  and 
are  quite  characteristic  of  this  affection.  They  consist  of  exulcerations, 
of  a  bright  red  color,  sharply  defined,  but  irregular  in  their  outline,  iso- 
lated at  first,  but  gradually  becoming  confluent.  They  are  due  simply  to 
the  epithelium  having  been  macerated  and  detached ;  and  they  form  a 
strong  contrast  in  color  with   other  portions  of  the   surface  on  which  the 


COMPLICATIONS. 


99 


Fijr.  23. 


latter  is  only  partially  detached,  but  Avbitened  by  constant  soaking. 
Sometimes  they  cover  the  whole  surface  of  the  glans,  leaving  no  trace 
whatever  of  its  normal  outer  layer. 

The  above  symptoms  may  be  still  further  aggravated.  The  prepuce 
becomes  of  a  dull  red  color,  and  its  oedematous  swelling  so  great  as  to  give 
to  the  virile  organ  the  shape  of  an  Indian  club  ;  sometimes  it  is  twisted 
in  the  form  of  a  corkscrew  in  front  of  the  glans.  The  discharge  is  in- 
creased in  quantity,  is  of  a  greenish  color,  and  streaked  with  blood.  Erec- 
tions are  frequent  and  very  painful.  The  passage  of  the  urine  is  impeded, 
amounting  in  some  cases  to  retention,  and,  when  accomplished,  is  attended 
with  intense  scalding  as  the  fluid  passes  over  the  fissured  orifice. 

Gangrene  of  the  prepuce  is  not  an  uncommon  occurrence.  It  is  usually 
[»artial,  in  fact,  just  sufficient  to  relieve  the  tension  and  allow  the  glans 
penis  to  protrude  through  the  opening  formed  by 
the  slough.  In  this  way  arise  the  oddest  deformi- 
ties, amusing  to  any  one  but  the  patient,  as  is  shown 
in  the  accompanying  wood-cut. 

One  attack  of  balanitis  predisposes  to  another. 
Men  with  a  long  prepuce  or  congenital  phimosis 
are  often  met  with,  who  have  lived  thirty  or  forty 
years  without  suffering  inconvenience  from  their 
malformation,  but  who,  after  one  attack  of  balanitis, 
are  constantly  subject  to  others,  following  inter- 
course with  healthy  women  or  even  mere  impru- 
dence in  diet.  In  consequence  of  a  succession  of 
such  attacks,  the  foreskin  is  changed  in  its  tex- 
ture, resembles  in  its  feel  leather  or  parchment,  and 
can  only  be  peeled  off  the  glans  with  some  difficulty. 
Its  orifice  and  internal  surface  and  the  surface  of 
the  glans  are  uneven,  dry,  and  beset  with  fissures 

which  readily  bleed.  In  one  case  which  came  under  my  care  the  patient, 
a  bell-hanger,  had  suflTei'ed  in  this  way  constantly  for  eight  years,  during 
most  of  which  time  he  had  been  in  the  hands  of  quacks,  who  told  him  he 
had  syphilis  and  treated  him  for  such. 

Frequent  attacks  of  balanitis,  especially  in  the  subacute  form,  favor  the 
development  of  vegetations  Avithin  the  balano-preputial  fold.  Adhesions 
may  also  take  place  between  the  o[)[)Osed  surfaces,  especially  in  the  furrow 
at  the  base  of  the  glans.  They  are  usually  limited  in  their  extent,  but  in 
rare  cases  become  general.  Without  having  actually  grown  together,  the 
two  surfaces  may  be  adherent  to  each  other,  as  if  glued  together,  and  may 
readily  be  separated  by  the  nail. 


Gangrene  of  prepuce  with 
glans  penis  button-holed. 


Complications Phimosis  and  paraphimosis  which  frequently  com- 

jtlicate  balanitis  will  form  the  subject  of  the  next  two  chapters. 

Lymphitis Inflammation   of  one  or  more   of  the  lymphatic  vessels 

running  along  the  dorsum  or  sides  of  the  penis  is  not  an  uncommon  com- 
plication of  acute  balanitis.     They  may  be  felt  like  hard,  sensitive  cords 


100  BALANITIS. 

niiniing  from  the  base  of  the  ghins  towards,  and  sometimes  extending  to, 
the  pubes.  Tiieir  course  may  be  visible  to  the  eye  by  a  reddish  line  upon 
the  skin  covering  them.  They  very  rarely  suppurate  unless  a  chancroid 
exist  beneath  the  prepuce. 

Adenitis The  glands  in  the  groin  occasionally  swell  and  become  slightly 

tender  and  painful,  but  rarely,  if  ever,  su])purate. 

Penitis General  inflammation  of  the  penis  is  said  sometimes  to  occur, 

marked  by  "  erysipelatous  redness  and  considerable  tumefaction  of  the 
whole  organ  ;  inflammatory  oedema  of  the  prepuce  extending  to  the  sheath 
of  tlie  penis,  which  is  painful  and  sensitive  to  the  slightest  contact ;  an 
abundant  phlegmonous  discharge  ;  lymphitis  and  swelling  of  the  inguinal 
glands.  Formidable  as  it  appears,  this  condition  most  frequently  termi- 
nates in  resolution,  though  sometimes  the  inflammation  extends  to  the 
cellular  tissue  and  produces  superficial  abscesses  and  even  gangrene." 
(Fournier.) 

Diagnosis. — The  presence  of  balanitis  is  easily  recognized.  The  diag- 
nosis of  the  cause  on  which  it  depends  is  not  always  quite  so  easy.  We 
Avill  consider  first  those  cases  in  which  the  glans  can  be  uncovered  and  the 
Avhole  balano-pi-eputial  fold  exposed  to  view,  and  next  those  more  diflftcult 
cases  in  which  phimosis  conceals  the  parts. 

In  the  former  an  inexperienced  observer  might  mistake  the  redness  sur- 
rounding a  patch  of  herpes  for  simple  balanitis,  but  the  characteristics  of 
herpes,  as  will  be  shown  in  another  cliapter,  are  sufficient  to  avoid  this 
error.  One  or  more  chancroids  situated  near  the  furrow  at  the  base  of 
the  glans  will  be  obvious  enough,  and  the  same  may  be  said  of  a  true 
chancre  with  an  ulcerated  surface  and  an  indurated  base,  the  diagnosis 
being  confirmed  by  the  induration  of  the  glands  in  the  groin.  More  dif- 
ficulty may  be  experienced  in  the  diagnosis  of  a  superficial  chancre,  which 
will  often  closely  resemble  one  of  the  exulcerated  patches  mentioned  as 
occurring  in  herpes.  It  is  generally,  however,  isolated,  causes  little  in- 
flammation of  the  surrounding  parts,  has  a  thin  layer  of  parchment  indu- 
ration beneath  it,  and  is  attended  by  induration  of  the  inguinal  ganglia. 

Secondary  eruptions  and  especially  mucous  patches  often  appear  on  the 
glans  near  the  furrow  in  the  early  stages  of  secondary  syphilis.  Tliey  are 
generally  multiple,  of  smaller  size  than  the  exulcerations  of  balanitis,  more 
regular  and  rounded  in  their  outline,  of  a  less  vivid  red  color,  and  are 
accompanied  by  other  secondary  symptoms  elsewliere. 

When  phimosis  is  present  and  the  balano-pre|)utial  fold  cannot  be  ex- 
posed, we  have  to  distinguish  between  a  discharge  coming  from  the  urethra 
and  the  discharge  of  balanitis.  Tiie  diagnostic  signs  have  been  given 
incidentally  on  jtage  07. 

The  presence  of  chancroids  beneath  the  prepuce  may  be  difficult  to  de- 
termine. It  is  almost  invariably  the  case,  however,  that  in  such  instances 
the  pus  from  these  ulcers  inoculates  the  fissures  at  tlie  preputial  orifice; 
hence  chancroids  of  the  pre[)utial  ring,  which  may  easily  be  seen  on  partly 
retracting  the  prepuce,  afford  a  presumption  of  their  existence  within  the 


TREATMENT.  101 

balano-preputial  fold.  Auto-inoculation  of  the  pus  may  be  practised  as 
a  test,  but  this  will  rarely  be  done  unless  the  question  of  an  operation 
comes  up. 

True  chancres  may  often  be  recognized  by  the  mass  of  induration  around 
them,  which  can  be  felt  by  the  fingers  externally.  Induration  of  the  glands 
in  the  groin  will  remove  all  doubt,  and  this  will  serve  also  to  indicate  the 
presence  of  superficial  chancres  which  might  otherwise  pass  unnoticed. 

Treatment — When  the  prepuce  can  be  retracted,  the  treatment  of 
balanitis  is  exceedingly  simple.  All  that  is  necessary,  in  most  cases,  is  to 
free  the  parts  from  any  collection  of  matter  by  gently  washing  them  with 
tepid  water,  and  then  to  cut  a  piece  of  lint  or  soft  linen  into  pieces  about 
an  inch  square,  and  laying  them  upon  the  glans  with  their  upper  margins 
well  up  in  the  furrow  behind  the  corona,  to  draw  the  prepuce  over  them. 
In  this  manner  the  inflamed  surfaces  are  isolated  from  each  other,  and 
speedily  take  on  a  more  healthy  action.  The  frequency  with  which  this 
application  should  be  repeated  depends  upon  the  copiousness  of  the  dis- 
charge ;  generally  from  two  to  four  times  in  the  twenty-four  hours  is  suffi- 
cient, and  a  cure  is  usually  attained  in  a  few  days  or  a  week.  In  severe 
cases,  however,  other  measures  than  those  mentioned  may  be  desirable. 
If  the  surface  be  excoriated,  it  is  well  to  pencil  it  over  lightly  with  a  crayon 
of  nitrate  of  silver,  or  to  apply  a  solution  of  this  salt,  of  the  strength  of 
twenty  or  thirty  grains  to  the  ounce  of  water. 

I  decidedly  prefer  to  use  the  lint  dry,  because  it  thus  better  absorbs  the 
matter  exuded.  Many  surgeons,  however,  moisten  it  with  some  lotion 
like  the  following: — 

I^.    Liquoris  Plnmbi  Diacctatis  5ij     •     .     .       81 

Aquffi  3ij 60| 

M. 

^.    Acidi  Tannici  5.1 41 

Glycerinae  §j 38J 

M. 

IJ;.     Liquoris  Sodte  Clilorinat.-e  ,^iij      ...     121 

Aqme  §v 150! 

M. 

^.    Extracti  Opii  9j 1  25 

Ziiici  Sulphatis  gr.  vj -40 

Glyci'riiKB  §j 38 

Aquae  §iij 90 

M. 

As  a  local  application  to  the  inflamed  surface  (after  washing  and  before 
the  introduction  of  lint),  iodoform  has  been  recommended.  This  may  be 
dissolved  in  ether,  one  drachm  to  the  ounce,  and  be  painted  on  with  a 
brush.  On  the  evaporation  of  the  ether,  which  causes  but  little  pain,  a 
thin  film  of  iodoform  is  left.  The  ether  j)artially  removes  the  bad  smell 
of  the  iodoform. 

Salves  beneath  the  prepuce  are  to  be  avoided;  so  also  poultices,  which 
favor  oedema. 

Cliancroids  should  receive  their  appropriate  treatment  and  true  chancres 


102  BALANITIS 

can  best  be  treated  and  their  induration  removed  by  the  internal  use  of 
niercurj. 

When  phimosis,  either  congenital  or  acquired,  exists,  the  parts  are  less 
accessible  to  treatment.  We  may  sometimes  succeed  in  enlarging  the 
preputial  orifice  and  thus  be  enabled  to  uncover  the  glans,  by  the  insertion 
of  a  few  small  pieces  of  compressed  sponge,  which  swell  under  the  moisture 
of  the  discharge  and  distend  the  ring. 

If  this  procedure  fail,  we  must  resort  to  injections  between  the  prepuce 
and  glans.  For  this  purpose  any  urethral  syringe  with  a  long  nozzle  may 
be  made  to  answer,  but  by  far  the  best  is  one  devised  by  Dr.  Robt.  W.  Tay- 
lor^ (Fig-  ^5).  It  consists  of  an  india-rubber  syringe,  to  which  is  attached  a 
nozzle  which  is  three  inches  long  and  nearly  flat,  having  a  diameter  of  less 
than  an  eighth  of  an  inch.  Near  the  end  of  it  and  situated  on  the  edge 
are  five  minute  holes,  two  on  each  side  and  one  on  the  extreme  end.  This 
nozzle  can  be  introduced  very  easily  and  without  pain  as  far  back  as  the 
fossa  glandis.  The  syringe  should  be  inserted  in  different  directions  and 
plain  water  at  first  be  thrown  in  until  the  prepuce  is  thoroughly  washed 
out,  as  may  be  known  from  the  returning  fluid  being  clear.  This  done,  a 
medicated  solution  should  be  thrown  in  and  Dr.  Taylor  prefers  a  solution 
of  carbolic  acid,  two  drachms  to  the  half  [)int  of  water.  These  injections 
should  be  repeated  five  or  six  times  a  day.  For  the  further  treatment  of 
supervening  phimosis,  see  the  next  chapter. 

If  the  balanitis  be  attended  by  much  infiltration  into  the  cellular  tissue 
of  the  prepuce,  the  fluid  should  be  evacuated  by  several  punctures  with  a 
lancet.  If  the  patient  can  keep  his  bed,  the  penis  may  also  be  enveloped 
in  a  single  thickness  of  linen,  ^y^it  with  cold  water  or  diluted  Goulard's 
extract,  and  exposed  to  the  air.  If,  however,  he  continues  his  daily  oc- 
cupation, no  benefit  can  be  expected  from  such  applications,  which,  when 
confined  by  the  clothes,  act  like  poultices,  and  favor  rather  than  prevent 
oedema.  In  all  cases  the  cure  of  balanitis  will  be  accelerated,  if  the  patient 
be  kept  quiet  and  the  parts  elevated. 

With  persons  who  have  repeated  attacks  of  balanitis  it  becomes  an 
important  object  to  take  measures  to  prevent  them.  To  accomplish  this 
the  strictest  cleanliness  should  be  enjoined.  The  parts  sliould  twice  a  day 
be  cleansed  of  all  accumulation  of  their  natural  secretion,  and  afterwards 
moistened  with  an  astringent  lotion,  as  a  mixture  of  equal  parts  of  brandy 
and  water  with  the  addition  of  alum,  a  solution  of  tannin,  or  any  of  the 
astringent  washes  already  mentioned.    A  good  formula  is  the  following  : — 

I^.     Acidi  Tannic!  5ij 8 

Aluminis  ^\v 16 

Glyceriiiffi  t^iij 15 

Aqure  §viij 250 

M. 

This  maybe  used  as  a  wash  or  it  may  be  put  up  in  a  wide-mouthed  phial 
and  the  penis  be  immersed  in  it. 

I  Am.  J.  Syph.  &  Derm.,  N.  Y.,  Oct.,  1872. 


TREATMENT.  103 

It  is  also  desirable  to  attend  to  the  digestive  functions,  and  to  regulate 
the  diet.  The  influence  of  a  long  prepuce  in  producing  relapses  of  this 
disease  has  already  been  referred  to.  1  have  sometimes  succeeded  in 
remedying  this  malformation  by  directing  the  patient  to  keep  his  prepuce 
constantly  reti-acted  by  means  of  a  narrow  bandage  applied  around  the 
penis,  posterior  to  the  glans.  If  this  be  worn  for  a  few  weeks,  the  prepuce 
will  often  remain  retracted  without  further  assistance,  and  the  mucous 
surface  of  the  glans  becomes  hardened  by  exposure  and  friction.  If  this 
attempt  prove  unsuccessful,  the  superfluous  integument  should  be  removed 
by  circumcision. 


104  PHIMOSIS. 


CHAPTER    IV. 
PHIMOSIS. 

The  term  Phimosis  is  applied  to  that  condition  of  tlie  penis  in  which  it 
is  impossible  to  retract  the  prepuce  behind  the  glans.  It  may  be  either 
congenital  or  accidental. 

Congenital  Phimosis In  the  majority  of  cases  phimosis  is  a  con- 
genital malformation  due  to  unnatural  narrowness  of  the  preputial  orifice, 
and  may  be  associated  with  adhesions  varying  in  position  and  extent 
between  the  glans  and  its  covering.  A  remarkable  instance  of  this  kind 
is  recorded  in  the  Surgical  Register  of  the  N.  Y.  Hospital:  Joseph  Smith, 
of  Prussia,  aged  49,  was  admitted  into  this  institution  Oct.  19,  1832,  with 
congenital  phimosis.  Dr.  Stevens  removed  the  free  portion  of  the  prepuce, 
which  was  found  to  be  attached  to  the  margin  of  the  meatus  instead  of  the 
base  of  the  glans,  and  formed  a  tubular  prolongation  of  the  urethra  nearly 
an  inch  in  length. 

Congenital  phimosis  is  a  source  not  only  of  great  inconvenience  to  the 
subject  of  it,  but  of  increased  exposure  to  venereal  diseases  in  promiscuous 
intercourse,  and  is  sometimes  the  cause  of  serious  disturbance  in  the 
genito-urinary  and  nervous  systems. 

Mr.  Jonathan  Hutchinson'  has  shown  by  statistics  that  syphilis  is  much 
less  common  among  Jews  than  among  Christians,  probably  on  account  of 
the  practice  of  circumcision  among  the  former.  At  the  Metropolitan  Free 
Hospital,  situated  in  the  Jews'  quarter,  London,  in  1854,  the  proportion 
of  Jews  to  Christians  among  the  out-patients  was  nearly  one  to  three ;  yet 
the  ratio  of  cases  of  sy{)liilis  in  the  former  to  those  in  the  latter  was  ooly 
one  to  fifteen ;  and  that  this  difference  was  not  due  to  their  superior  chastity- 
was  evident  from  the  fact  that  the  Jews  furnished  nearly  half  the  cases  of 
gonorrhoea  that  were  treated  during  the  same  period.  Mr.  Hutchinson's 
observations  also  lead  him  to  believe  that  hereditary  syphilis  is  much  rarer 
among  the  children  of  Jews  than  Christians  ;  and  the  experience  of  most 
surgeons  will  confirm  the  fact  tliat  persons  with  a  long  prepuce,  and  espe- 
cially those  affected  with  congenital  phimosis,  are  peculiarly  subject  to 
venereal  diseases. 

The  size  of  the  preputial  orifice  in  congenital  phimosis  varies  in  dif- 
ferent cases.  In  some,  it  is  large  enough  to  permit  of  the  partial  exposure 
of  the  glans  and  the  removal  of  the  natural  secretion  of  the  part,  at  least 
with  the  assistance  of  a  syringe  and  injections  of  warm  water ;  while  in 

'  Mod.  Tiiiios  and  Gaz.,  Lond.,  Dec.  1,  1855. 


CONGENITAL    PHIMOSIS.  105 

Others,  it  is  so  contracted  that  it  is  difficult  or  even  impossible  to  uncover 
the  meatus ;  whence  it  happens  that  the  entrance  of  the  urine  at  each  act 
of  mictLirition  beneath  the  prepuce,  and  the  collection  of  sebaceous  mat- 
ter, maintain  a  constant  state  of  irritation  and  even  chronic  inflammation, 
to  which  most  of  the  adhesions  met  with  between  the  opposed  surfaces  are 
undoubtedly  attributable. 

Daily  observation  proves  that  congenital  phimosis  is  not  inconsistent 
with  a  state  of  perfect  health  ;  and  yet  when  we  reflect  upon  the  sympathy 
existing  between  different  portions  of  the  genito-urinary  apparatus,  and 
between  the  latter  and  other  organs,  we  might  reasonably  expect  to  meet 
with  at  least  occasional  instances  in  which  irritation  of  the  head  of  the 
penis  due  to  this  cause  gives  rise  to  disturbance  in  other  parts  of  the  body. 
These  anticipations  are  realized  in  practice  ;  but,  according  to  Fleury,' 
who  has  ably  investigated  this  subject,  such  disturbance  is  to  be  attributed 
more  to  the  extreme  sensitiveness  of  the  balano-preputial  membrane  con- 
stantly protected  from  friction  and  exposure  to  the  air,  than  to  the  irrita- 
tion of  collections  of  sebaceous  matter  ;  since  it  is  often  present  even  when 
the  condition  of  the  parts  admits  of  the  most  perfect  cleanliness. 

Among  the  ill  effects  ascribed  to  congenital  phimosis  are :  balanitis, 
constant  itching  and  even  pain  at  the  head  of  the  penis,  inordinate  ex- 
citability of  the  genital  organs,  frequent  erections,  erotic  dreams,  seminal 
emissions,  imperfect  development  of  the  penis  and  testicles,  incomplete 
and  painful  ejaculation  of  the  sperm,  vesical  tenesmus,  incontinence  of 
urine,  gastralgia,  neuralgia,  and  genei-al  lassitude  and  prostration.  Prob- 
ably no  one  will  be  disposed  to  call  in  question  the  occasional  connection 
between  the  milder  of  the  above  affections  and  phimosis.  Thus  no  one 
can  doubt  that  boys  with  congenital  phimosis  are  peculiarly  prone  to  suffer 
from  nocturnal  incontinence  of  urine,  of  wdiich  they  are  cured  by  circum- 
cision ;  that  at  a  more  advanced  age  the  penis  does  not  attain  its  full 
development ;  that  they  are  more  apt  to  practise  masturbation  and  to  have 
seminal  emissions  ;  that  in  married  life  they  do  not  have  the  full  enjoy- 
ment of  the  sexual  act,  the  usual  complaint  being  of  too  speedy  ejacula- 
tion ;  and  that  during  life  they  are  subject  to  disagreeable  sensations  and 
to  attacks  of  balanitis,  which  are  even  aggravated  in  old  age  when  the 
integument  generally  becomes  loose  and  flabby.  The  same  is  equally 
true  of  persons  witli  a  long  prepuce,  even  if  no  actual  phimosis  be  present. 

With  regard  to  the  more  remote  effects  of  congenital  phimosis,  some 
doubts  might  be  legitimately  entertained,  were  it  not  for  the  circumstan- 
tial report  of  the  symptoms,  and  the  fact  that  simple  excision  of  the  elon- 
gated prepuce  has  in  many  cases  brought  complete  and  permanent  relief.^ 

Witiiin  tiie  last  few  years  additional  cases  of  the  remote  effects  of  con- 

'  Gaz.  tl.  h6p.,  Paris,  Oct.  30,  18.51. 

"  Fleuky's  observations  have  been  fully  confirmed  by  Borelli  {Maladies  genito- 
risicalcs,  Gaz.  d.  /i6p.,  Paris,  Dec.  1851)  ;  Anagnostaxls  relates  a  cure  of  ambly- 
opia by  the  excision  of  the  prepuce  {Rev.  de  (h^rap.  m^d.-chir.,  No.  4,  IS.'iO).  See 
also  an  article  by  John  II.  Packard,  M.D.,  "On  Congenital  Phimosis"  (Am.  Jour. 
Med.  Sci.,  Oct.,  1870) 


106  PHIMOSIS. 

genital  phimosis  and  of  a  small  meatus  urinarius  have  been  reported  by 
Drs.  Sayre,  Moses,  Otis,  Green,  Bro\vn-8equard,  and  others.  These 
cases  have  been  ably  summed  np,  and  others  added,  in  a  report  from  the 
Surgical  Section  to  the  New  York  Academy  of  IMedicine,  by  Dr.  Yale,' 
who  says  :  "  The  forms  of  nervous  disturbance  observed  in  these  cases,  so 
far  as  I  have  ascertained,  have  been,  notably,  incoordination  of  muscular 
movements,  including  those  necessary  to  speech,  less  commonly  spasm  or 
spastic  contraction,  and  paresis,  generally  of  the  lower  extremities.  I 
find  no  case  of  paralysis  of  sensation,  but  hypera:sthesia  is  often  men- 
tioned. Several  cases  of  amblyopia  have  been  published.  A  mental  con- 
dition resembling  hysteria  or  hypochondriasis  is  a  frequent  element  in  the 
clinical  histories." 

Verneuil  reports  a  very  interesting  case  in  which  careful  microscopical 
examination  of  the  excised  prepuce  showed  that  the  terminal  plexus  of 
nerves  had  become  hypertrophied,  and  in  which  the  nervous  symptoms 
were  thus  fully  accounted  for.^ 

Accidental  Phimosis. — Accidental  phimosis  may  depend  upon  any 
cause  enlarging  the  glans  penis  to  such  an  extunt  that  it  will  not  pass 
through  the  preputial  orifice,  or  occasioning  such  an  amount  of  tliickening 
or  contraction  of  the  prepuce  that  it  cannot  be  retracted ;  in  other  words, 
the  seat  of  the  difficulty  may  be  either  in  the  glans  or  its  covering. 

In  some  cases  the  obstruction  is  simply  mechanical,  as  from  vegetations 
within  the  balano-preputial  fold,  the  induration  surrounding  a  chancre,  or 
the  cicatrization  of  any  ulcer  situated  upon  tiie  margin  of  the  prepuce. 

More  frequently  it  originates  in  inflammatory  action,  as  idiopathic 
balanitis  or  posthitis,  or  the  same  affections  excited  by  the  presence  of 
ulcers,  secondary  eru|)tions,  vegetations,  etc.,  either  of  which  may  occa- 
sion swelling  of  the  glans  or  infiltration  in  tlie  lax  cellular  tissue  of  the 
prepuce. 

M.  Bourgade  (Progres  med.,  Paris,  Sept.  2,  1876)  has  observed  four 
cases  of  phimosis  due  to  the  irritating  action  of  the  saccliarine  urine  of 
diabetes  upon  the  meatus,  glans,  and  prepuce,  and  states  that  a  surgical 
operation  is  useless  so  long  as  the  cause  persists.  M.  Verneuil  and  M. 
Comillon,  of  Vichy,  have  observed  similar  cases.  The  former  says  a 
confrere  of  his  has  lost  two  patients  on  whom  he  imprudently  operated  for 
diabetic  phimosis. 

There  is  still  another  cause  of  phimosis  which,  strictly  speaking,  cannot 
be  included  among  those  just  mentioned  ;  I  refer  to  a  peculiar  thickening 
of  the  mucous  membrane  and  submucous  tissue,  observed  both  in  men 
and  women  after  tlie  cicatrization  of  a  chancroid  or  chancre,  and  which 
consists  neither  in  specific  induration  nor  oedema,  but  in  liypertro|)liy  of 
the  normal  tissues  of  the  organ.  Gosselin  believes  that  this  effect  is  i)ecu- 
liar  to  venei'eal  ulcers.     It  is  most  frequently  found  in  the  labia  minora  in 

'  See  N.  York  M.  J.,  Aug.,  1877. 

2  Arch.  gen.  de  iu6d.,  Paris,  Nov.,  18G1. 


TREATMENT.  107 

women,  and  in  the  prepuce  in  men.  In  the  latter  the  envelope  of  tlie 
glans  may  become  so  thickened  that  its  retraction  may  be  very  difficult 
and  give  rise  to  iissures  of  the  preputial  orifice,  or  may  be  quite  impos- 
sible. 

Treatment In  congenital  phimosis  attended  by  any  of  the  unpleas- 
ant effects  alluded  to  at  the  commencement  of  this  chapter,  circumcision 
is  the  only  sure  means  of  relief.  I  would  go  even  farther  than  this,  and 
say,  that  every  case  of  congenital  phimosis,  if  persistent  on  the  approach 
to,  or  after  puberty,  demands  the  ablation  of  the  prepuce,  whether  any 
unpleasant  consequences  have  ever  manifested  themselves  or  not.  It 
would  be  well  for  the  future  comfort  and  health  of  tlie  individual,  if 
fathers  would  inquire  into  and  attend  to  this  matter  as  their  sons  approach 
adult  age.  If,  from  any  cause,  an  operation  be  impracticable,  the  subject 
of  congenital  phimosis  should  be  directed  at  each  act  of  micturition  to 
expose  the  meatus  as  fully  as  possible  in  order  to  prevent  the  entrance  of 
the  urine  beneath  the  prepuce,  and  intra-preputial  injections  should  be  re- 
sorted to  if  sebaceous  matter  accumulates  or  any  signs  of  inflammation 
appear.  The  best  syringe  for  this  purpose  is  one  with  a  broad,  flattened 
nozzle,  to  facilitate  its  introduction  between  the  prepuce  and  glans,  as 
proposed  by  Dr.  R.  W.  Taylor.     (See  Fig.  2.5.) 

In  accidental  phimosis,  the  rule  commonly  accepted  is  to  avoid  an 
operation  if  possible,  unless  congenital  phimosis  has  previously  existed  ; 
but  when  due  to  vegetations  beneath  the  prepuce,  or  to  contraction  of  the 
preputial  orifice  from  the  cicatrix  of  a  chancroid  which  has  entirely  healed, 
an  operation  may  be  necessary  to  gain  access  to  the  abnormal  growths  or 
to  restore  the  opening  of  the  prepuce  to  its  original  size. 

Phimosis  dependent  upon  a  large  mass  of  specific  induration  disappears 
under  the  internal  administration  of  mercurials. 

An  operation  should,  if  possible,  be  avoided  or  deferred  when  the  phi- 
mosis is  due  to  acute  inflammation,  which  may  in  most  cases  be  subdued 
by  rest  in  the  horizontal  posture,  low  diet,  cathartics,  leeches  to  the  groin 
or  perin;\3um  (not  upon  the  prepuce),  a  lead  and  opium  wash,  and,  if  it  be 
certain  that  no  chancroid  is  present,  by  scarifications.  The  orifice  of  the 
prepuce  may  sometimes  be  dilated  so  as  to  permit  retraction  of  the  latter 
by  inserting  between  it  and  the  glans  a  number  of  pieces  of  compressed 
sponge,  or  Nelaton's  phimosis  forceps  may  (Fig.  24)  be  employed. 

In  some  instances  we  are  certain  that  an  ulcer  is  concealed  between  the 
prepuce  and  glans,  where  it  may  have  been  seen  either  by  the  patient  or 
surgeon  before  the  phimosis  supei'vened  ;  in  others,  its  existence  is  highly 
probable,  from  the  fact  that  the  patient  has  been  exposed  in  promiscuous 
intercourse.  Now  the  mere  suspicion  of  an  ulcer  within  the  hidden  folds 
of  mucous  membrane  is  sufficient  to  induce  caution  in  resorting  to  an 
operation  which  may  be  followed  by  inoculation  of  the  edges  of  the  wound. 
It  is  indeed  true  that  if  the  sore  be  a  chancre,  auto-inoculation  will  not 
be  likely  to  take  place ;  but  it  may  be  of  the  mixed  variety,  or  there  may 
be  both  a  true  chancre  and  a  chancroid ;    hence  the  fact   that  a  mass  of 


108  PHIMOSIS. 

induration  can  be  felt  beneath  the  prepuce  is  not  sufficient  of  itself  to 
justify  an  operation.  A  case  in  point  has  fallen  under  my  own  observa- 
tion :  A  medical  friend  was  called  to  treat  a  case  of  phimosis  dependent 
upon  an   ulcer,  surrounded   by  a  cartilaginous   mass  of  induration  which 

Fijr.  24. 


Nt'laton's  Phimosis  Forceps. 

could  be  felt  beneath  the  prepuce.  Relying  upon  the  fact  that  a  chancre 
cannot  readily  be  inoculated  upon  the  person  bearing  it,  he  resorted  to  an 
operation  ;  but  in  a  few  days  the  edges  of  the  wound  assumed  tlie  appear- 
ance of  a  chancroid.  In  doubtful  cases  the  nature  of  the  secretion  may 
be  tested  by  auto-inoculation  before  resorting  to  circumcision. 

Under  some  circumstances,  however,  and  especially  with  gangrene 
threatening,  an  operation  cannot  be  avoided.  The  question  then  comes 
up  in  what  manner  it  shall  be  jierformed.  In  the  inflamed  condition  of 
the  parts,  with  the  prepuce  infiltrated,  thickened,  brawny,  and  perhaps 
threatening  gangrene,  circumcision  is  for  obvious  reasons  not  to  be  thought 
of.  The  immediate  object  to  be  attained  is  to  relieve  tension  and  to  expose 
the  balano-preputial  fold  so  as  to  admit  of  local  applications  and  attention 
to  cleanliness. 

The  method  commonly  adopted  under  these  circumstances  has  been  to 
slit  up  the  prepuce  along  the  dorsum  by  means  of  a  curved  bistoury  guided 
by  a  director,  which  has  first  been  introduced  from  the  orifice  to  the  angle 
of  reflexion.  Tiie  objections  to  this  method  are  two  :  In  the  first  place, 
if  there  is  much  thickening  of  the  prepuce  it  does  not  fully  expose  the 
parts  ;  the  flaps  on  either  side  are  too  unyielding  and  too  sensitive  to  en- 
able us  to  bend  them  back  and  reach,  for  instance,  chancroids  situated  in 
the  sulcus  near  the  frnsnum.  In  the  next  place,  the  ultimate  result  of  the 
operation  is  undesirable.  Two  "  dog's  ears"  are  left  which  are  anything 
but  elegant  or  useful  in  this  situation,  and  which  require  a  subsequent 
bloody  operation  for  their  removal. 

For  these  reasons  I  prefer  the  procedure  recommended  by  Dr.  R.  W. 
Taylor,  in  his  paper  on  phimosis,  already  referred  to.  This  consists  in 
making  two  incisions,  one  on  either  side,  exactly  in  tlie  middle  of  the 
lateral  portion  of  the  prepuce,  either  by  means  of  a  bistoury,  or,  prefera- 
bly, with  a  pair  of  strong  scissors  (Fig.  25),  such  as  those  devised  by  Dr. 
Taylor  for  this  purpose. 


TREATMENT. 


109 


The  result  of  this  operation  is  that  the  prepuce  is  converted  into  two 
flaps — an  upper  and  a  lower — with  the  glans  penis  between  them,  and  the 
upper  flap  can  be  elevated  and  the  lower  one  depressed  with  the  greatest 
ease,  so  as  to  expose  the  whole  surface.     Then,  after  the  acute  disease  has 


Fi£r.  25. 


Taylor's  Phimosis  Scissors. 
Taylor's  Syringe  for  sub-preputial  injections. 


subsided  and  the  edges  of  the  incisions  have  healed,  these  flaps  may  be 
snipped  off  without  confining  the  patient  to  the  house  or  taking  him  away 
from  business. 

But,  it  will  be  objected,  you  thus  have  double  the  amount  of  raw  surface 
exposed  to  contagion.  Very  true,  but  the  advantage  gained  is  more  than 
a  counterbalance,  and,  moreover,  if  the  incision  be  properly  cauterized 
and  dressed,  contagion  will  in  most  cases  be  avoided.  The  caustic  pre- 
ferred by  Dr.  Taylor  is  pure  carbolic  acid,  rendered  fluid  by  a  small  quan- 
tity of  water.  Four  pieces  of  lint  are  to  be  cut — tw^o  to  fit  the  glans,  the 
one  above  and  the  otlier  below — and  two  strips  to  place  between  the  cut  sur- 
faces. These  pieces  of  lint  are  soaked  in  the  acid  and  put  in  their  places; 
the  flaps  are  then  brought  together  and  a  bandage  wound  round  the  penis, 
allowing  the  meatus  to  be  free.  The  whole  should  be  kept  wet  with  cold 
water,  and  the  dressing  repeated  daily  until  the  parts  are  healed. 

The  thickening  of  the  substance  of  the  prepuce,  already  described  as  a 
sequela  of  venereal  ulcers,  is  rarely  so  great  as  to  produce  complete  phi- 
mosis ;  but  the  difficulty  attending  the  exposure  of  the  glans  and  the  fre- 
quent rents  which  tlie  act  occasions,  often  justify  the  removal  of  the  hy- 
pertrophied  tissues. 

Befoi'c  describing  this  operation,  let  me  remind  the  student  that  the 
prepuce  is  composed  of  two  layers,  separated  by  a  cellular  tissue  of  such 
lax  texture  as  to  admit  of  an  almost  indefinite  amount  of  motion  between 
them.  The  internal  or  mucous  layer  is  firmly  attaciied  to  the  penis  pos- 
terior to  the  corona  glandis,  and  hence  is  incapable  of  being  drawn  forwards 
to  any  ^reat  extent  in  front  of  the  glans.  Tlie  external  or  integumental 
layer,  on  the  contrary,  is  continuous  with  the  flaccid  skin  of  the  body  of 
the  penis,  and  may  be  greatly  elongated  ;  its  anterior  portion  doubling  in 


110 


PHIMOSIS. 


upon  itself  as  the  posterior  is  drawn  forwards.  It  follows  from  this  ana- 
tomical arrangement  that  a  section  of  the  prepuce  in  front  of  the  glans 
can  only  include  the  integumental  together  with  an  insignificant  portion 
of  the  mucous  layer. 

Of  the  various  methods  of  performing  circumcision  recommended  by 
dilFerent  authors,  I  prefer  the  following  : — 

The  patient  should  be  upon  the  bed  where  he  is  to  lie  until  cicatrization 
is  accomplished,  in  order  after  the  operation  to  avoid  unnecessary  motion 
and  hemorrhage,  which  would  interfere  with  speedy  union ;  and  it  is  de- 
cidedly best  that  he  should  be  etherized.  The  requisite  instruments  are 
a  pair  of  long-bladed  forceps,  a  sharp-pointed  bistoury,  blunt-pointed 
scissors,  and  sutures  of  very  fine  silk.  Henry's  forceps,  represented  in 
Fig.  26,  are  the  best  on  this  occasion,  although  any  long  forceps  will 
answer. 

Fig.  26. 


Henry's  Phimosis  Forceps. 

A  tape  may  be  tied  around  the  base  of  the  penis  near  the  pubes  to  re- 
strain the  hemorrhage.      Allow  the  penis  to   hang  without  traction   in  its 


Fig.  27. 


natural  condition,  and,  if  your  eye  is  not   a  sufficiently  accurate  guide, 
trace  with  a  pen  and  ink  a  line  upon  the  skin  corresponding  to  the  corona 


TREATMENT. 


HI 


glandis,  to  serve  as  a  guide  for  the  incision.  Next  draw  the  prepuce  for- 
wards, until  this  line  is  in  front  of  the  glans,  and  grasp  it  from  above 
downwards  between  the  long  blades  of  the  forceps,  which  should  be  in- 
trusted to  an  assistant ;  the  external  part  is  now  to  be  excised  in  front  of, 
and  close  to  the  blades  of  the  forceps,  having  first  been  put  upon  the 
stretch  by  the  left  hand  of  the  operator.  Any  attempt  to  cut  from  either 
margin  of  the  fold  will  be  attended  Avitli  some  difficulty,  since  the  several 
layers  of  the  skin  and  mucous  membrane  oppose  an  amount  of  resistance 
to  the  knife  that  is  not  readily  overcome  ;  hence,  it  is  better  to  transfix 
the  centre  of  the  flap  (the  blade  of  the  knite  parallel  to,  in  front  of,  and 
in  contact  with  the  forceps),  cut  downwards,  and  complete  the  section  by 
turning  the  knife,  and  cutting  upwards  (Fig.  27). 

The  assistant  ^should  now  remove  the  forceps,  when  the  integument  will 
retract,  carrying  its  cut  edge  back  to  the  base  of  the  glans,  and  exposing 
the  raw  external  surface  of  the  mucous  membrane  which  still  covers  the 
glans  (Fig.  29).  If  the  mucous  membrane  be  in  a  healthy  condition  it 
may  be  divided  with  scissors  along  the  dorsum,  and  turned  back  to  be 
united  to  the  integument ;  but  if  thickened  by  chronic  inflammation,  vege- 
tations, or  the  cicatrix  of  an  ulcer,  the  flap  (E,  B,  B)  on  either  side  should 
be  excised.  Indeed  the  latter  course  is  always  best,  with  this  important 
proviso,  however :  don't  cut  off  the  whole  of  the  flap  quite  down  to  the 
line  of  its  insertion,  if  you  do  you  will  find  the  introduction  and  removal 
of  your  sutures  difficult,  and  union  by  first  intention  is  less  likely  to  be 
attained ;  hence,  make  your  cuts  on  either  side  so  as  to  leave  about  half 
an  inch  of  the  mucous  membrane  behind. 

This  ablation  of  the  flaps  may  be  done  by  successive  cuts  with  ordinary 
curved  scissors,  on  a  line  parallel  with  the  corona  glandis  ;  or  further  accu- 
racy may  be  secured  by  the  assistance  of  Horteloup's  phimosis  forceps^ 


Fig.  28 


Horteloup's  I'liimosis  Forceps  (2  actual  size). 

(P^'ig.  28),  which,  placed  astraddle  on  the  penis,  are  made  to  grasp  the  flap, 
and  the  redundant  membrane  is  then  excised  by  one  stroke  of  a  bistoury. 
If  tlie  frienum  is  short,  divide  it.  Several  little  arteries  may  spirt  in 
your  face,  quiet  them  with  a  good  twist  of  the  torsion  forcieps,  and  keep 
the  bleeding  surface  exposed  to  the  air  for  a  few  minutes  until  you  are 
sure  all  bleeding  has  ceased,  unless  you  wish  to  be  called  from  your  bed 
the  coming  night.  Tliere  is  still  a  little  cut  desirable,  which  I  have  for  a 
long  tinitt  employed,  and  which  has  rec(Mitly  been  mentioned  by  Dr.  Keyes 


'  Bull.  gun.  dv  th(5rap.,  etc,  I'aris,  1878,  p.  559. 


112 


PHIMOSIS. 


(Van  Buren  and  Keyes,  p.  11).  This  cut  is  made  with  scissors  in  the 
retracted  integument  along  the  dorsum  to  a  point  (A)  about  one-quarter 
of  an  inch  behind  the  free  margin,  and  the  edges  of  the  incision  ((7,  C) 
are  to  be  rounded  off.  Its  object  is  to  insure  perfect  freedom  from  con- 
striction at  the  line  of  division,  without  which  both  cicatrization  will  be 
delayed  and  the  ultimate  condition  of  the  parts  be  less  satisfactory. 


Fijr.  29. 


Fio;.  30. 


>    - 


For  the  purpose  of  uniting  the  edges  of  the  wound  some  surgeons  em- 
ploy serres-fines,  and  others  silver  sutures.  The  foi'mer  are  likely  to  be 
detached  by  the  movements  of  the  patient  before  he  recovers  from  the 
ether,  and  the  latter  are  too  stiff  to  be  removed  without  unnecessary  pain. 
If  very  fine  silk  be  used — such  as  is  employed  by  oculists  in  operations 
upon  the  eye — it  will  be  found  to  possess  all  the  advantages  of  metallic 
sutures,  and  may  be  left  in  for  a  week  without  causing  suppuration.  More- 
over, instead  of  using  interrupted  sutures,  as  is  usually  done,  if  we  employ 
the  continuous  suture  commencing  at  the  fraiuum,  it  will  be  found  that 
this  part  of  the  operation  ran  be  finished  in  one-quarter  of  the  time  and 
the  edges  will  be  much  better  adapted  to  each  other,  as  seen  in  Fig.  30. 

Simple  exposure  to  the  air,  and  ])rotection  by  means  of  a  cradle  from 
contact  with  the  bedclothes,  is  all  tliat  is  retpiired  for  tlie  first  twelve  hours, 
after  which  a  water-dressing  may  be  applied.  The  patient  should  remain 
in  bed  until  the  parts  have  nearly  healed,  and,  if  contact  of  the  urine  with 
the  wound  cannot  be  otherwise  prevented,  should  micturate  with  his  penis 
immersed  in  a  basin  of  tej)id  water.  In  favorable  cases,  confinement  to 
the  house  for  three  to  five  days  is  sufl[icient. 

It  would  hardly  seem  necessary  to  caution  the  surgeon  not  to  excise  too 
large  a  portion  of  the  integument,  were  it  not  for  the  following  case  re- 
ported by  Nelaton  :^  A  patient  appeared  at  the  clinique  who  had  been 
operated  upon  for  phimosis  eleven  days  before  by  the  usual  method.  The 
physician,  forgetting  that  the  integument  of  the  penis  is  very  lax  and 
extensible,  had,  before  making  the  incision,  drawn  it  forwards  to  its  utmost 
limits  ;  the   consequence  was  thiit,  aft(M-  tlie  o[)eration,  the   penis  was  de- 


'   Pathologie  chiiurgi(^ale,  t.  v.  p.  663. 


TREATMENT.  113 

nuded  nearly  to  the  abdominal  wall.  An  extensive  suppurating  surface 
had  remained,  which  was  torn  and  made  to  bleed  by  frequent  erections. 
The  case  does  not  appear  to  have  been  followed  to  its  termination,  but 
Nelaton  remarks  upon  the  rigidity  and  malformation  of  the  organ,  pro- 
vided cicatrization  should  take  place,  and  adds  that  "  this  case  shows  the 
importance  of  marking  the  limits  of  the  incision  before  the  operation." 

The  American  editor  of  Erichsen's  Surgery  states  that  the  favorite 
operation  for  phimosis  at  the  Pennsylvania  Hospital,  Philadelphia,  consists 
in  simple  division  of  the  mucous  layer  of  the  prepuce,  by  means  of  fine 
scissors,  one  blade  of  which  is  sharp,  and  the  other  probe-pointed.  The 
former  is  made  to  penetrate  between  the  two  layers  of  the  prepuce  along 
the  dorsum  of  the  organ,  while  the  latter  passes  between  the  glans  and  its 
envelope,  and  thus  the  internal  layer  may  be  divided  as  far  as  the  corona 
glandis.  The  prepuce  should  be  retracted  several  times  each  day,  espe- 
cially during  micturition,  both  in  order  to  prevent  contact  of  the  urine 
with  the  wound,  and  also  immediate  union,  which  would  tliwart  the  pur- 
pose of  the  operation. 

Faure  accomplishes  the  division  of  the  mucous  layer  in  a  simpler  man- 
ner, as  follows  :  The  skin  of  the  penis  is  forcibly  drawn  towards  the  abdo- 
men, when  an  incision  is  made  with  blunt-pointed  scissors  upon  the  dorsum 
of  the  retracted  preputial  orifice,  implicating  the  mucous  membrane,  but 
sparing  the  integument.  This  allows  of  a  still  further  retraction  of  the 
pi'epuce,  bringing  into  view  an  additional  portion  of  mucous  membrane, 
which,  by  a  succession  of  the  above  procedures,  may  be  divided  to  the 
base  of  the  glans. 

Dr.  Hue,^  of  Rouen,  instead  of  dividing  the  prepuce  with  a  cutting 
instrument,  passes  a  needle  through  its  dorsal  surface  close  to  the  base 
of  the  glans,  and  ties  the  portion  of  skin  in  front  of  the  puncture  with  an 
elastic  ligature,  which  is  said  to  cut  its  way  through  in  three  or  four  days. 
Dr.  H.  states  that  he  has  operated  with  satisfactory  results  by  this  method 
in  eighty  cases,  comprising  both  adults  and  children. 

Jobert  (de  Lamballe)  makes  an  incision  from  the  pi-eputial  orifice  on 
each  side  of  the  fra^num  as  far  as  the  corona  glandis  ;  then  cuts  off  the 
fraanum,  which  is  now  included  in  a  small  triangular  flap  ;  and  finally 
unites  the  skin  and  mucous  membrane  by  the  interrupted  suture,  thus 
leaving  the  greater  portion  of  the  prepuce  intact  and  merely  enlarging  its 
orifice  beneath.^ 

Tiiese  methods,  unattended  by  any  loss  of  substance,  may  suffice  when 
it  is  desired  sim^Jy  to  relieve  uncomplicated  phimosis;  but  when  the 
mucous  membrane  is  in  a  diseased  condition,  as  is  genei'ally  the  case  when 
an  operation  is  required,  circumcision  should  be  preferred. 

'  Doctor,  bond.,  Nov.  1,  1878,  p.  235. 
^  Uaz.  d.  hdp.,  Paris,  27  Aug.,  1861. 


114 


PARArHIMOSIS. 


CHAPTER    V. 


PARAPHIINIOSIS. 


The  term  Paraphimosis  implies  exactly  the  opposite  of  phimosis,  viz., 
the  retracted  prepuce  cannot  again  be  drawn  forward  so  as  to  envelop  the 
glans.  This  condition  is  often  met  with  in  boys  with  a  tight  prepuce,  as 
the  result  of  their  first  attempt  to  expose  the  glans ;  again  it  may  follow 
coitus  with  a  woman  whose  vulvar  orifice  is  small,  or  it  is  often  produced 
by  patients  themselves  by  retraction  of  the  prepuce  for  the  purpose  of  in- 
specting or  dressing  some  venereal  affection  with  which  they  are  afflicted. 
Having  thus  exposed  the  glans  and  ignorant  of  the  danger  of  thus  leaving 
it  for  any  lengtli  of  time,  they  allow  the  prepuce  to  stay  back  and  soon  find 
it  impossible  to  bring  it  forward  again.      The  tight  preputial  orifice  has 


Fiff.  31. 


,..«-.^^j^j:^« 


Paraphimosis.    (After  JuUien.) 

acted  like  a  ring  constricting  the  penis  ;  the  glans  has  in  consequence  be- 
come congested  and  swollen,  and  in  any  attempt  at  reduction  the  preputial 
ring  meets  with  obstruction  from  the  abrupt  base  of  the  corona,  such  as  the 
knuckle  offers  to  a  tight  ring  on  the  finger.  The  swelling  goes  on  increas- 
ing; the  submucous  and  sub-integumental  cellular  tissue  becomes  infiltrated 
with  serum,  and  the  parts  present  the  appearance  represented  in  Fig.  31. 
Now  it  is  to  be  observed  that  the  constricting  ring,  the  preputial  orifice, 


PARAPHIMOSIS. 


115 


is  buried  in  the  first  furrow  seen  as  we  proceed  from  tlie  base  of  the  glans 
backwards ;  the  swollen  fold  between  it  and  the  glans  is  the  preputial 
mucous  membrane  retracted;  the  folds  back  of  it  are  folds  of  the  integument 
of  the  prepuce  and  body  of  the  penis  ;  the  greatest  amount  of  the  ojdema 
is  found  in  the  lax  cellular  tissue  below  in  the  neighborhood  of  the  frse- 
num  ;  the  glans  itself  is  swollen  and  tilted  backwards  so  that  the  meatus 
looks  somewhat  upwards. 

If  the  case  be  left  to  itself,  nature's  course  (we  can  hardly  call  it  cure) 
is  as  follows  : — the  constricting  ring,  in  its  portion  upon  the  dorsum  of  the 
penis,  is  attacked  by  ulceration  and  gangrene,  first  involving  only  the  skin 
and  subjacent  cellular  tissue,  and  appearing  as  a  series  of  antero-posterior 
fissures  wliich  soon  unite  and  form  a  transverse  open  ulcer  Avith  irregular 
borders.  The  ulcerative  process  deepens  until  it  has  eaten  through  the 
fibrous  ring  beneath,  when  the  constriction  is  relieved,  the  patient's  suffer- 
ing is  at  an  end  and  the  ccdema  soon  disappears. 

All  cases,  however,  do  not  terminate  thus  fortunately.  The  ulcerative 
process  may  result  in  gangrene,  involving  a  large  portion  of  the  integument 
and  the  glans,  and  even  opening  into  the  urethra.  Venot^  reports  a  case 
in  which  one-third  of  the  glans  was  lost.  Auger^  relates  a  case,  in  which 
the  ui'ethra  was  opened  to  the  extent  of  one  centimetre  (four-tenths  of  an 

Fig.  32. 


"  Sub-preputial  frill."      (After  JuUien.) 

inch).  Through  erosion  of  a  vein  or  artery,  copious  hemorrhage  may  occur. 
.Suppurative  inflammation  may  invade  the  cellular  tissue  and  destroy  the 
integument  of  the  penis  to  a  greater  or  less  extent.  Erysipelas,  i)hlebitis, 
and  lymphangitis  are  still  other  dangers,  to  which  patients  with  paraphi- 
mosis are  exposed. 


'  .1.  de  met!,  et  cliir.  prat.,  Paris,  1836,  p.  347. 
«  Union  med.,  P.iris,  1872,  p.  91. 


]1B 


PARAPHIMOSIS. 


In  all  or  nearly  all  cases,  which  are  not  early  treated,  adhesions  form 
between  the  skin  and  the  upper  surface  of  the  corpora  cavernosa,  rendering 
any  later  attempt  at  reduction  impossible.  Moreover,  after  the  patient 
has  been  relieved  by  the  destruction  of  the  ring  and  the  ulceration  has 
healed,  these  adhesions  remain.  A  depressed  cicatrix  is  left  by  the  ulcer, 
and  the  lower  portion  of  the  prepuce,  which  is  now  redundant,  continues 
swollen  and  thickened.  The  appearance  of  the  organ  is  well  represented 
in  Fig.  32. 

Under  these  circumstances,  a  subsequent  operation  is  evidently  required 
to  restore  to  the  organ  its  pristine  elegance  and  usefulness. 

The  above  symptoms  are  those  of  the  inflammatory  form  of  paraphimosis, 
which  is  the  most  common.  There  is  another  indolent  form,  in  which 
there  is  scarcely  more  than  mere  oedema  of  the  prepuce  without  inflamma- 
tory action,  and  in  which  reduction  is  easily  effected. 

Treatment When  called  to  a  case  of  paraphimosis,  it  may  not  be 

advisable  to  attempt  reduction  until  the  cedema  has  first  been  diminished 
by  rest  in  the  horizontal  posture,  elevation  of  the  penis,  and  a  saline  cathar- 
tic, assisted  in  some  instances  by  scarification  of  the  swollen  tissues  in 
front  of  the  stricture,  the  application  of  ice  or  a  stream  of  cold  water 
directed  upon  the  part. 

Attempts  at  reduction  are  extremely  painful  and  it  is  hence  desirable  to 
put  the  patient  under  the  influence  of  ether.  Chloroform  should  not  be 
used  in  this  nor  in  other  minor  operations,  if  ever.  The  difficulty  of  re- 
duction is  frequently  increased  by  the  vicious  manner  in  which  the  attempt 
is  made.  The  swollen  glans  and  mucous  layer  of  the  prepuce  are  to  be 
passed  through  a  narrow  preputial  orifice.  Mere  pressure  from  before 
backwards  will  increase  their  transverse  diameter  and  augment  the  diffi- 
culty of  reduction  ;  this  can  be  best  accomplished  by  compressing,  and,  if 

necessary,  elongating  them,  and  drawing;, 
the  constricting  ring  and  integumental 
layer  over  them. 

^Multiple  punctures  with  a  lancet  should 
be  made  in  tlie  swollen  tissues  in  front 
of  the  constriction,  and  these  parts,  after 
having  been  well  com[)ressed  and  kneaded 
between  the  fingers,  so  as  to  evacuate  as 
mucli  of  the  infiltrated  serum  as  possible, 
had  better  be  oiled.  The  surgeon  then 
encircles  the  body  of  the  penis  with  the 
thumb  and  forefinger  of  the  left  hand  in 
the  manner  represented  in  Fig.  33,  and 
thus  secures  a  base  of  support.  With  the 
fingers  of  his  right  hand,  he  now  still 
further  compresses  the  glans  in  its  trans- 
verse diameters  for  several  minutes,  and 
then  endeavors  to  insert  the  nail  of  his 


Fig.  33. 


TREATMENT.  117 

thumb  or  index  finger  beneath  the  constricting  ring  on  its  dorsal  aspect,  at 
the  same  time  tucking  under  the  hitter  the  fold  of  mucous  membrane  in  front. 
As  soon  as  he  succeeds  in  this  attempt  and  can  feel  the  ring  riding  up  on  his 
nail,  he  knows  that  no  firm  adhesions  have  formed,  and  he  has  an  inclined 
plane  on  which  to  complete  the  reduction.  His  efforts,  however,  should  not 
be  for  a  moment  relaxed  until  the  whole  is  completed,  or,  otherwise,  the  parts 
will  slip  back  into  their  former  position. 

M.  Bardinet^  employs  a  hair-pin  in  a  similar  manner  to  the  above.  He 
describes  his  method  as  follows  : — "  I  bend  the  glans  on  its  anterior  (lower) 
aspect  and  gently  draw  the  skin  of  the  penis  forwards  from  behind  the 
constriction.  I  then  attempt  to  insert  the  bend  of  a  hair-pin  between  the 
preputial  ring  and  the  body  of  the  penis.  This  done,  I  have  two  levers  in 
the  branches  of  the  pin,  wiiich  I  move  back  and  forth  for  a  triple  purpose, 
to  depress  the  prominence  of  the  base  of  the  glans,  to  elevate  the  preputial 
ring  and  to  secure  an  inclined  plane  upon  which  it  may  gently  be  made  to 
glide." 

Before  Badinet,  however,  the  late  Abraham  CoUes,  Prof,  of  Surgery  at 
the  Royal  College  of  Surgeons  in  Ireland,  succeeded,  after  other  means 
had  failed,  in  relieving  two  severe  cases  of  paraphimosis,  by  passing  a  di- 
rector beneath  the  stricture  from  before  backwards,  and  elevating  it  upon 
the  point  of  the  instrument,  while  the  stem  was  made  to  compress  the 
swelling  in  front,  and  gradually  force  it  back  beneath  the  stricture.  This 
process  was  repeated  on  each  side  of  the  penis,  after  which  reduction  w^as 
quite  easy.^ 

After  reduction  has  been  accomplished,  the  parts  should  be  kept  ele- 
vated and  covered  with  some  cooling  application  until  the  swelling  has 
disappeared. 

The  above  methods  are  recommended  as  the  most  worthy  of  adoption. 
Among  the  many  others  proposed,  we  may  mention  the  following  : 

In  one  proposed  by  M.  Garcia  Teresa,  the  centre  of  a  piece  of  tape  is 
placed  upon  the  dorsum  of  the  corona  glandis,  the  opposite  ends  passed 
round  the  sides  of  the  glans,  crossed  beneath  the  frisnum,  and  wound 
around  the  little  finger  of  each  hand;  the  glans  is  then  compressed  by  flex- 
ing the  middle  and  ring  fingers,  and  exercising  traction  in  opposite  direc- 
tions, wliile  the  other  fingers  remain  free  to  draw  the  prepuce  forwards, 
and  accomplish  its  reduction.* 

Dr.  Van  Dommelin  effects  compression  of  the  glans  by  winding  around 
it  a  strip  of  adhesive  plaster  half  a  yard  long,  and  about  a  quarter  of  an 
inch  wide,  commencing  at  its  base,  and  terminating  near  the  orifice  of  the 
urethra.* 

M.  Seutin,  of  Brussels,  has  invented  a  pair  of  forceps  with  spoon-shaped 
extremities,  to  maintain  compression  of  tlie  glans  until  the  constricting  ring 
can  be  drawn  over  them. 

'  Nouveau  proc6(le  dc  reduction  <lii  paraphimosis,  Union  mfii.,  Paris,  1873,  p.  OOC. 

2  Dublin  Q,  J.  M.  So.,  May,  1657. 

3  Rev.  do  therap.  mM.-cliir.,  Fob.  15,  1860. 
*  Med.  Times  and  Gaz.,  bond.,  Juno  4,  1859, 


118  PARAPHIMOSIS. 

The  three  preceding  methods  are  designed  for  the  purpose  of  com- 
pressing the  glans  during  reduction;  in  tlie  following,  which  is  said  to  be 
em[)loyed  with  great  success  at  the  Children's  Hospital,  in  Pesth,  com- 
pression of  nearly  the  whole  organ  precedes  the  attempt  to  restore  the 
preputial  orifice  to  its  normal  position. 

The  penis  is  first  well  cleansed  and  dried,  when  a  strip  of  adhesive  plas- 
ter, about  three  lines  broad,  is  applied  longitudinally  from  the  middle  of 
its  under  surface,  over  the  swollen  prepuce  and  glans,  avoiding  the  meatus, 
to  the  middle  of  the  upper  surface.  Another  strip  is  cai'ried  in  a  similar 
manner  from  side  to  side  over  the  glans,  and  in  large  boys  a  third,  and 
even  a  fourth,  strip  may  be  required  to  cover  the  whole  organ.  Finally, 
still  another  strip  is  firmly  applied  transversely  over  the  pi-eceding,  com- 
mencing just  behind  the  meatus,  and  continued  by  successive  turns  to  the 
middle  of  the  body  of  the  penis.  The  application  is  said  to  be  well  borne, 
and  the  swelling  so  diminished  within  twenty-four  hours,  that  the  plaster 
must  be  renewed;  reduction  can  usually  be  effected  within  forty -eight 
hours. ^ 

Many  years  ago,  Mazade'*  extolled  the  effects  of  frequent  applications  of 
belladonna  ointment.  In  one  case  of  obstinate  paraphimosis,  after  three 
applications,  the  prepuce  was  less  engorged,  and  the  glans  less  in  size.  The 
following  day,  after  only  tliree  drachms  of  the  extract  of  belladonna  had 
been  used,  reduction  was  accomplished  without  difficulty.  Jullien  states 
that  this  result  has  since  been  confirmed  by  Moulas  and  Langlebert. 

When  reduction  is  impossible,  and  ulceration  or  gangrene  threatens, 
it  becomes  necessary  to  relieve  the  stricture,  by  dividing  the  preputial 
ring,  which — as  should  not  be  forgotten — is  situated  at  the  base  of  the 
furrow  between  the  swollen  folds  of  mucous  membrane  and  integument. 
This  may  be  done  by  entering  a  narrow,  sharp-pointed  bistoury  flatwise, 
and  from  befwe  backwards,  upon  the  dorsum  of  the  penis,  turning  its  edge 
upwards,  and  dividing  the  stricture.  In  some  cases,  this  procedure  must" 
be  repeated  in  several  places,  and  the  swollen  prepuce  freely  scarified, 
before  reduction,  if  not  prevented  by  adliesions,  can  be  eftected,  or  at  any 
rate,  before  relief  can  be  obtained. 

It  is  an  interesting  historical  fact  that  Ambrose  Pare^  believed  it  neces- 
sary to  amputate  the  penis  in  cases  of  parapliimosis,  in  order  to  avoid  gan- 
grene and  save  the  life  of  the  patient. 

The  best  operation  for  removing  the  deformity  (Fig.  32)  sometimes  left 
by  paraphimosis  is  one  proposed  by  Mauriac  :*  two  lines  are  drawn  with 
ink,  one  anterior  and  the  other  posterior,  both  of  them  starting  from  the 
extremities  of  the  transverse  cicatrix  on  the  dorsum  of  the  penis.  The 
anterior  line  is  made  to  run  parallel  with  the  corona  glandis  and  about 
four-tenths  of  an  inch  from  it.  The  posterior,  starting  from  the  same  ter- 
minal points,  is  so  drawn  as  to  run  behind  the  sub-preputial  tumor,  which 

'  Schmidt's  Jahrb.,  Leipz. 

2  J.  de  med.  et  chir.  prat.,  Paris,  1834,  p.  445. 

^  Chap,  xxxi,  book  xvii. 

*  Memoire  sur  le  paraphimosis,  Paris,  1872,  p.  28. 


TREATMENT.  119 

is  now  circumscribed  by  two  curves  forming  an  ellipse.  An  incision  is 
now  made  following  each  line  through  the  skin  only  ;  after  which,  the  sub- 
cutaneous mass,  which  is  infiltrated  and  hypertrophied,  is  removed  by  a 
deep  dissection.  The  edges  of  the  wound  ai-e  finally  stitched  together, 
and  union  by  first  intention  almost  always  takes  place. 


120  FOLLICULITIS    AND    PERI- URETHRAL    PHLEGMON. 


CHAPTER    Yl. 

FOLLICULITIS   AND  PERI-U  RETH  R  A  L   PHLEGMON. 

These  two  affections  resemble  each  other  in  their  seat,  but  are  entirely 
distinct  in  their  anatomical  characters,  and  demand  different  modes  of  treat- 
ment. The  fii'st  is  an  inflammation  of  the  follicles  of  Morgagni  which 
open  into  the  urethra;  the  second,  inflammation,  always  resulting  in  sup- 
puration, of  the  cellular  tissue  underlying  the  corpus  spongiosum. 

Folliculitis This  affection  is  by  no  means  common  but  is  occasionally 

met  with  in  cases  of  gleet  following  severe  attacks  of  urethritis.  The  mode 
of  its  production  is  as  follows.  The  inflammation  of  the  urethral  mucous 
membrane  extends  to  the  cavities  of  the  follicles,  produces  hypertrophy  of 
their  lining  membrane  and  obliterates  their  ducts  ;  hence  the  normal  secre- 
tion of  the  gland  mingled  with  pus  is  pent  up  in  the  cavity,  which  it 
distends  in  the  form  of  a  small  tumor  or  intra-glandular  abscess.  These 
abscesses  have  been  studied  especially  by  Dr.  Ch.  Hardy, ^  who  describes 
them  as  follows  : — 

"In  the  early  stage  of  its  formation,  this  abscess  or  rather  this  cyst  is 
often  overlooked.  Only  when  it  has  attained  the  size  of  a  pea,  is  it  per- 
chance noticed.  It  then  appears  in  the  form  of  a  small  tumor,  either 
globular  or  ovoid,  sometimes  bilobed,  occupying  the  lower  surface  of  the 
urethra,  to  which  it  is  attached  by  a  narrow  pedicle,  which  is  nothing  more 
than  the  obliterated  and  elongated  excretory  duct.  This  tumor  is  subcu- 
taneous, hard,  and  movable  under  the  skin,  which  preserves  its  normal 
appearance  ;  it  is  little,  or  not  at  all,  sensitive  to  the  touch.  When  it  has 
lasted  for  some  time  and  has  attained  the  size  of  a  small  nut,  it  becomes 
soft  and  possibly  shows  on  palpation  signs  of  fluctuation,  which  is  rarely 
very  distinct.  These  abscesses  are  often  multiple.  We  have  seen  three 
in  a  patient  who  had  had  them  over  four  months. 

"  These  follicular  abscesses  pursue  an  essentially  chronic  course,  and 
resemble  very  much,  in  their  symptoms  and  their  mode  of  termination,  the 
'  wens'  that  appear  on  tlie  scalp.  After  remaining  stationary  for  a  long 
time,  they  suddenly  become  sensitive  to  the  touch,  increase  rapidly  in  size, 
contract  adliesions  with  the  overlying  skin,  which,  if  they  are  not  incised, 
they  perforate  and  vent  themselves  by  a  narrow  opening,  which  remains 
fistulous.  They  do  not  present  the  same  danger  as  do  abscesses  of  the  peri- 
urethral cellular  tissue;  they  show  no  tendency  to  open  into  the  urethra. 

"  All  that  is  required  for  the  cure  of  these  abscesses  is  to  cut  down  upon 

'   Mimoiie  sur  les  absc^s  hlennonhuf/iques,  Paris,  1864. 


PERT  URETHRAL  PHLEGMON. 


121 


the  cyst  and  enucleate  the  whole  of  it,  as  is  done  with  'Avens'  on  the 
scalp ;  or  else,  simplj  cut  out  a  portion  of  the  fibrinous  envelope,  taking 
care  to  keep  the  wound  open.  Resolution  of  these  tumors  can  never  be 
obtained  by  ordinary  means." 


Fig.  34. 


Follicular  abscess.     (After  Hardy.) 

An  extreme  case  of  a  follicular  abscess,  forming  a  pedunculated  tumor 
on  the  under  surface  of  the  penis,  is  represented  in  Fig.  34. 

Inflammation  of  Cowper's  glands  will  be  considered  in  a  separate  chapter. 

Pkri-urethkal  Phlegmon — This  affection,  situated  in  the  cellular 
tissue  underlying  the  urethra,  is  much  more  common  than  the  former,  and 
is  said  to  be  m.et  with  in  attacks  of  gonorrhtea  which  have  been  decidedly 
acute  or  in  patients  who  have  indulged  in  excesses  to  the  neglect  of  treat- 
ment. I  have  one  patient,  however,  in  whom,  it  seems  to  be  the  inevitable 
attendant  upon  each  attack  of  gonorrhoea.  He  has  had  the  clap  four  times 
and  every  time  a  peri-urethral  abscess,  so  that  he  now  predicts  this  com- 
plication whenever  the  first  symptoms  of  a  fresh  clap  show  themselves. 
This  affection  may  occur  at  any  point  along  the  under  surface  of  the 
urethra  from  the  glans  penis  to  the  bulbous  region,  but  is  much  more 
frequent  just  beneath  the  fossa  navicularis  and  at  tlie  peno-scrotal  angle 
(in  front  of  the  bulb)  than  elsewhere.  These  are  the  two  points  at  which 
gonorrht?a  is  most  likely  to  persist,  but  whether  the  frequency  of  phlegmons 
in  these  situations  can  thus  be  explained  is  a  mooted  question  and  is  of 
little  importance;  the  fact  only  need  be  noticed. 


122 


FOLLICULITIS    AND    PERI- URETHRAL    PHLEGMON. 


Any  premonitory  symptoms  of  the  formation  of  a  peri-urethral  phleg- 
mon are  usually  insignificant  and  are  only  recalled  by  the  patient  after  the 
mischief  has  been  done,  when  he  will  recollect  (?)  that  he  has  felt  more  or 
less  pain  for  some  time  at  the  point  involved  ;  this  pain  perhaps  over- 
shadowed by  the  more  urgent  symptoms  of  his  gonorrhoea. 

Fig.  35. 


Phlegmon  limited  to  one  side  nf  the  fra;num.     (After  Hardy.) 


Fig.  36. 


Phlegmon  divided  by  the  fi«iium  into  two  lobes.     (After  Hardy.) 


PERI-URETHRAL    PHLEGMON. 


123 


Suppuration  has  very  likely  taken  place  when  the  surgeon's  attention  is 
called,  and  is  evident  upon  palpation  of  the  projecting  tumor,  which  is  sen- 
sitive on  pressure  and  surrounded  by  more  or  less  oedema.  The  patient 
experiences  pain  at  the  part  involved,  and,  in  rare  instances,  there  is  gen- 
eral constitutional  disturbance,  shown  by  chills,  fever,  loss  of  appetite,  etc. 
The  pressure  of  the  tumor  upon  the  urethra  may  affect  the  force  and  shape 
of  the  stream  of  urine  or  occasion  dysuria  amounting  even  to  retention. 

The  seat  of  the  abscess  is  not  without  influence.  When  beneath  the 
fossa  navicularis,  it  rarely  exceeds  the  size  of  a  cherry  and  is  globular  in 
form  (Fig.  35)  ;  it  may  be  on  one  or  the  other  side  of  the  fra^num,  or,  when 
developed  in  the  median  line,  be  bilobed  in  consequence  of  the  constriction 
of  this  bridle  (Fig.  36). 

An  abscess  occurring  near  the  bulb,  at  the  peno-scrotal  angle  (Fig.  37), 
is  usually  larger  and  may  reach  the  size  of  an  English  walnut  or  more. 
Commonly  occupying  the  median  line,  it  may,  however,  be  lateral.     It 

Fig.  37. 


Phlegmon  at  peno-scrotal  angle.     (After  Hardy.) 

may  extend  around  the  scrotum  and  involve  the  perinajum  or,  less  fre- 
quently, it  invades  the  penis.  The  skin  covering  it  is  of  the  normal  color. 
These  phlegmons  never  undergo  resolution  ;  their  only  termination  is  sup- 
puration. 

The  abscess  most  frecpiently  and  favorably  opens  externally  and  cica- 
trization rapidly  takes  place.  Again  it  may  break  into  the  urethra ;  in 
which  case,  its  cavity  is  exposed  to  the  entrance  of  the  urine  and  there  is 
danger  of  urinary  infiltration  and  gangrene  of  the  cellular  tissue  of  the 


124  FOLLICULITIS    AND    PERI-URETHR AL    PHLEGMON. 

penis  and  scrotum.  Finally  the  abscess  may  break  both  externally  upon 
the  surface  and  also  into  the  canal. 

Treatment. — These  phlegmons  should  always  be  incised  as  soon  as  dis- 
covered, even  if  fluctuation  is  not  as  yet  distinct,  and  the  cut  should  be 
kept  open  until  the  abscess  has  completely  emptied  itself.  If  one  has 
opened  spontaneously  into  the  urethra,  the  (piestion  comes  up  whether  a 
counter  opening  should  be  made  from  without.  Most  authorities  pursue 
this  course.  Fournier,  on  the  contrary,  prefers  to  wait,  closely  watching 
the  case  and  prepared  to  act  in  the  event  of  infiltration,  which,  he  says,  is 
not  nearly  so  common  as  supposed.  "  It  is  probable  that  the  opening  is 
often  very  minute  and  closes  as  the  abscess  discharges  itself,  so  that  the 
entrance  of  urine  into  the  cavity  is  prevented." 

It  is  evident  that  the  patient  is  exposed  to  the  formation  of  a  urinary 
fistula,  which  is  more  frequent  near  the  bulb  than  at  the  glans.  "  When 
occurring  at  the  latter  place  it  gives  rise  to  an  accidental  hypospadias 
which  is  difficult  to  cure."     (Hardy.) 


INFLAMMATION    OP    COWPER's    GLANDS.  125 


CHAPTER    VII. 
INFLAMMATIOX   OF   COWPER'S   GLANDS. 

This  is  a  rare  complication  of  urethral  gonorrlioea  in  the  male,  but 
sometimes  occurs  at  about  the  same  period  as  epididymitis,  viz.,  during 
the  third  or  fourth  week,  or  later  after  the  appearance  of  the  discharge. 

The  patient  experiences  a  feeling  of  tension  and  pain  in  the  perinteum 
near  the  bulb  of  the  urethra,  which  is  aggravated  in  the  sitting  posture, 
by  walking  and  by  friction  of  the  clothes.  Upon  palpation  a  small  tumor 
of  the  size  of  a  bean  is  felt  upon  either  side  of  the  median  line;  its  form 
ovoid  or  pyriform,  witli  its  base  directed  towards  the  anus  and  its  apex 
connected  with  the  bulb.  This  tumor  may  encroach  upon  the  urethra  and 
cause  dysuria,  and  on  introducing  a  catheter  an  obstruction  may  be  met 
with  near  the  bulb.     Defecation  is  also  painful. 

Resolution  is  possible,  but  in  most  cases  suppuration  takes  place,  some- 
times in  the  gland  itself,  but  more  frequently  in  the  surrounding  cellular 
tissue,  and  the  abscess  extends  to  the  base  of  the  scrotum,  often  crosses  the 
raphe  to  the  opposite  side,  and,  in  rare  instances,  involves  the  whole  of 
the  perinfeum.  Tiie  matter  usually  finds  exit  in  the  perinanim,  and  an 
opening  may  also  form  in  the  urethra,  giving  rise  to  a  urinary  fistula ; 
sinuses  may  also  be  formed  in  various  directions. 

In  a  patient  who  died  of  some  intercurrent  disease,  Littre  found  "  the 
body  of  the  gland  extremely  hard,  red,  and  tumefied,  and  a  greenish- 
yellow  fluid  could  be  pressed  out  of  it.  The  duct  of  the  left  gland  was 
distended  with  a  similar  fluid,  and  its  tunics  were  of  a  reddish  color,  and 
harder  and  tiiicker  than  normal.  The  urethra,  in  front  of  the  openings 
of  the  glandular  ducts,  was  reddened  over  a  space  of  about  four  lines  in 
width,  and  in  the  middle  of  this  space  there  was  a  rounded  ulcer  half  a 
line  in  diameter  which  liad  eaten  away  a  large  portion  of  the  opening  of 
the  left  duct  and  a  small  portion  of  the  canal  in  the  neighborhood.'" 

The  gland  to  the  left  of  the  raphe  is  said  to  be  most  frequently  attacked. 
Sometimes  both  glands  are  involved.  The  formation  of  matter  is  often 
accompanied  by  general  febrile  disturbance.  Since  these  glands  are  not 
surrounded  by  a  fibi'ous  capsule  like  the  prostate,  urinary  infiltration  is 
likely  to  occur  when  the  abscess  breaks  into  the  urethra,  and  we  may 
have  diffuse  suppuration  of  the  cellular  tissue.  Tarnowski  si)eaks  of  atre- 
sia of  the  uretliral  openings  of  the  ducts,  as  one  of  the  results  of  this  affec- 
tion ;  the  remainder  of  tlie  duct  becomes  dilated,  cyst-like,  and  may  inter- 
fere with  the  passage  of  urine  by  its  pressure  on  th<3  urethra. 

The  treatment  of  this  affection  consists  in  the  early  application  of 
leeches,  hot  baths,  poultices,  and  rest,  and  incision  of  the  tumor  so  soon  as 
it  is  evident  that  resolution  is  impossible  even  if  fluctuation  be  not  clearly 
detected. 

'  LriTR^,  as  quoted  by  Founiier. 


126  AFFECTIONS    OF    THE    CORPORA    CAVERNOSA. 


/ 


CHAPTER    VIII. 
AFFECTIONS    OF   THE    COKPORA   CAVERNOSA. 

In  the  course  of  an  attack  of  gonorrhoea,  the  inflammation  may  extend 
to  the  corpora  cavernosa  and  produce  an  effusion  of  plastic  lymph,  which 
will  obliterate  the  cavities  of  these  bodies  and  interfere  with  complete  dis- 
tention in  the  state  of  erection  of  the  penis.  "  The  same  effect  may  be 
produced  by  small  apoplectic  deposits  in  the  substance  of  the  corpora 
cavernosa,  the  cicatrization  of  which  always  entails  a  deposit  of  a  certain 
quantity  of  plastic  tissue"  (Robert). 

In  consequence  of  such  deposits  the  penis  may  be  bent  in  such  a  manner  as 
seriously  to  interfere  with  coitus ;  the  concavity  of  the  bend  looking  upwards, 
downwards  or  laterally  according  as  the  deposit  is  situated  in  either  of  these 
directions.  If  both  bodies  be  invaded  at  any  one  point,  the  portion  of 
the  penis  behind,  i.  e.  towards  the  pubes,  may  alone  be  distended,  while 
the  anterior  portion  remains  flaccid.  The  occurrence  of  these  deposits  is 
attended  at  the  outset  by  a  fusiform  swelling  of  the  penis  and  pain  on  deep 
pressure.  They  usually  continue  in  an  indolent  condition,  are  but  little 
amenable  to  treatment,  and  may  be  a  source  of  great  annoyance  and 
mental  despondency. 

The  same  condition  as  that  now  described,  may  be  the  result  of  mechan- 
ical injuries  to  the  penis  when  erected,  or  of  gummy  deposits  occurring  in 
syphilis. 

As  to  treatment,  the  attempt  may  be  made  to  induce  absorption  by 
local  frictions  with  an  ointment  containing  mercury  or  the  iodide  of  lead, 
and  by  the  internal  use  of  the  iodide  of  j)0tassium. 

Chronic  circumscribed  Inflammation  op  the  Corpora  Caver- 
nosa  Under  this  title  Van  Buren  and  Keyes^  first  clearly  described  an 

aflection,  which  was  little  known  and  barely  referred  to  in  works  on  Surgery 
and  Venereal  Diseases,  although  mentioned  by  II.  J.  Johnson^  in  1851. 
The  affection  is  free  from  pain  and  progresses  slowly,  until  the  patient 
notices  a  small  lump  which  is  painful  on  erection  of  the  penis.  Upon  ex- 
amination we  find  a  hard  fii-m  plate  of  tissue,  a  line  or  two  in  thickness, 
situated  in  the  superficial  portion  of  the  corpus  cavernosum.  Its  margins 
are  sharply  defined  and  regular,  or  they  may  be  uneven,  slightly  nodulated 
and  perhaps  thickened.  The  deeper  parts  seem  to  be  free  from  disease. 
The  induration  of  the  plate  is  variable,  in  some  cases  being  cartilaginous, 

'  A  Practical  Treatise  on  Diseases  of  the  Genito-Urinary  Organs,  New  York,  1874. 
2  Lancet,  Lond.  1851. 


INFLAMMATION    OF    THE    CORPORA    CAVERNOSA.  127 

but  it  always  has  a  kind  of  elasticity,  which  gives  to  the  finger  a  sensation 
quite  different  from  that  offered  by  the  bony  and  calcareous  plates  some- 
times found  here.  The  lesion  may  occupy  one  corpus  cavernosum  or  both, 
and  always  seems  to  spring  from  the  median  line  on  the  dorsum  of  the  penis. 
The  plate  generally  has  an  ovoid  shape,  but  in  two  instances,  in  which  the 
disease  was  seated  about  an  inch  behind  the  corona  glandis,  we  found^on 
either  side  a  horn-like  process  or  offshoot  extending  around  to  the  frtenum 
along  the  course  of  the  lymphatics.  The  lesion  is  always  circumscribed 
and  seldom  exceeds  half  an  inch  in  diameter ;  we  have  never  seen  a  plate 
more  than  two  inches  in  diameter.  When  each  corpus  cavernosum  is  in- 
vaded the  plates  may  be  firmly  united  on  the  dorsum  of  the  penis,  or  they 
may  be  separate.  There  is  no  increase  of  heat  in  the  affected  parts,  nor 
is  the  skin  above  the  tumor  at  all  abnormal.  Tlie  affection  is  extremely 
chronic  and  sometimes  intermittent.  The  plates  may  grow  antero-pos- 
teriorly,  or  they  may  remain  stationary,  or  they  may  extend  in  one  direc- 
tion as  they  disappear  at  the  opposite  end,  thus  travelling  over  nearly  the 
whole  length  of  the  corpus  cavernosum.  Spontaneous  pain  is  rare,  but  the 
parts  are  always  sensitive  to  pressure,  and  there  may  be  a  dull  aching  sen- 
sation along  the  border  of  the  patch.  The  lesion  interferes  with  erection, 
the  penis  being  drawn  towards  the  affected  side  ;  when  it  involves  both 
sides  of  the  penis  the  organ  may  be  bent  upwards  to  such  a  degree  as  to 
prevent  coitus. 

The  affection  has  been  met  with  only  in  those  of  middle  or  advanced 
age.  Its  etiology  is  very  obscure.  In  some  cases  it  seems  to  have  re- 
sulted from  injury ;  although  occurring  in  those  who  have  had  syphilis, 
gonorrhoea,  or  stricture,  there  seems  to  be  no  relation  between  the  diseases. 

We  know  nothing  positive  of  the  pathology  of  the  affection,  but  it  is 
probably,  as  suggested  by  Iveyes,  "  in  its  essence  a  chronic  inflammation 
of  a  peculiar  kind  affecting  the  erectile  tissue  at  a  certain  point  and  so 
thickening  and  stiffeniiig  the  naturally  thin  walls  of  the  areohie  (probably 
filling  up  the  interstices  with  fibrinous  exudation),  that  they  cannot  be  dis- 
tended with  blood  during  erection  of  the  rest  of  the  organ." 

The  prognosis  of  the  disease  is  uncertain.  There  is  no  case  on  record 
in  which  it  disappeared  altogether.  In  most  cases  the  plates  persist  for 
many  years ;  sometimes  they  diminish  very  markedly  in  size,  but  they  never 
become  excessively  large  nor  undergo  degeneration. 

Treatment  of  various  kinds  has  been  tried  with  little  if  any  benefit. 
We  fully  agree  with  Van  Buren  and  Keyes  in  deprecating  the  use  of  blis- 
ters and  counter-irritants,  since  they  are  painful  and  inefiicacious.  Friction 
with  dilute  mercurial  ointment  and  the  occasional  use  of  the  constant  cur- 
rent, with  iodine  internally,  may  promote  absorption  of  the  deposit. 


128  LYMPHANGITIS    AND    ADENITIS. 


CHAPTER    IX. 

LYMPHANGITIS    AND    ADENITIS. 

GoxoRRiiosAL  lymphangitis  may  either  be  seated  in  the  principal  trunks 
or  in  the  reticular  network  of  these  vessels. 

I.  In  the  former,  the  course  of  the  inflamed  lymphatics  can  be  traced  as 
reddish  lines,  running,  as  is  usually  the  case,  along  the  dorsum  of  the  penis 
from  the  prepuce  towards  the  pubes.  There  may  be  one  or  several.  In 
the  latter  case  they  may  be  united  by  transverse  bands  of  erythema, 
corresponding  to  the  anastomoses  of  the  vessels.  To  the  touch  they 
resemble  hard  or  knotted  cords,  which  can  be  separated  by  the  fingers  from 
the  adjacent  tissues.  Their  sensitiveness  varies  with  the  amount  of  in- 
flammation. There  is  often  some  cedema  of  the  prepuce  or  of  the  penis 
and  tenderness  of  the  inguinal  ganglia.  This  state  of  things  almost 
invariably  terminates  in  resolution.  Suppuration  is  reported  to  occur  in 
rare  instances  in  the  form  of  several  small  circumscribed  abscesses,  which 
are  usually  of  little  moment,  but  which  may  undermine  the  skin  to  some 
extent  and  demand  surgical  interference  (Hardy).  Zeissl  says  he  knows 
men  who  have  lymphangitis  every  time  they  have  the  clap. 

Fournier  speaks  of  another  form  of  this  affection  taking  place  (afroid) 
without  any  signs  of  acute  inflammation  and  recognizable  only  by  the  hard 
and  indolent  cord  or  cords,  perceptible  to  the  touch  along  the  dorsum  of 
the  penis,  and  readily  mistaken  for  the  indurated  lymphangitis  attend;uit 
ujjon  the  initial  lesion  of  syphilis. 

Inflammation  of  the  lymphatic  trunks  along  the  dorsum  of  the  penis  has 
been  mistaken  for  dorsal  phlebitis.  According  to  Fournier,  the  latter  is 
an  exceedingly  rare  affection,  a  few  cases  having  been  seen  by  Ricord. 
It  is  distinguishable  from  the  former  by  the  greater  amount  of  ojdema,  by 
the  impossibility  of  grasping  and  isolating  the  vessel  between  the  fingers, 
and  by  the  inguinal  ganglia  remaining  unafix^cted. 

II.  The  second  form  of  lymphangitis,  the  one  in  which  the  general 
reticular  network  of  the  lymphatic  vessels  is  involved,  is  usually  confined 
to  the  prepuce  and  is  responsible  for  many  of  the  cases  of  phimosis  and 
paraphimosis  and  their  sequelae  (abscesses,  perforation  of  the  prepuce,  etc.) 
which  have  been  described  in  another  chapter.  The  part  affected  is  of  a 
uniform  rose  or  red  color,  more  or  less  tumefied  and  exceedingly  sensitive. 
The  trunks  of  the  vessels  along  the  dorsum  and  the  glands  in  the  groin 
usually  show  signs  of  participation. 

In  very  rare  cases  the  whole  penis  is  involved,  attains  an  enormous  size, 
is  twisted  upon  itself  at  its  extremity,  and  is  the  seat  of  the  most  violent 
pain.    Micturition  is  difficult  and  [lainful,  erections  excruciating.     General 


ADENITIS.  129 

febrile  reaction,  chills,  fever,  loss  of  appetite  and  even  delirium  (it  is  said) 
may  complete  the  bill  of  fare. 

In  most  cases  even  these  severe  symptoms  terminate  without  any  un- 
toward result.  Suppuration,  however,  is  a  consequence  to  be  feared. 
'*  When  this  takes  place,  it  is  almost  always  seated  in  the  prepuce.  Very 
rarely  it  involves  the  cellular  tissue  lining  the  sheath  of  the  penis.  The 
abscess  shows  great  tendency  to  destroy  the  mucous  membrane  of  the  pre- 
puce and  to  empty  itself  towards  the  glans.  When  finally  emptied,  the 
swelling  of  the  prepuce  subsides,  the  tension  disappears,  the  pains  cease, 
and  the  skin  can  be  felt  to  be  thinned  at  the  point  affected.  In  some  cases 
this  thinning  of  the  skin  is  so  great  that  the  membrane  loses  its  vitality  and 
is  affected  with  gangrene.  A  perforation  results,  through  which  the  glans 
may  be  seen.  This  accident  is  not  the  only  one  to  which  the  patient  is 
exposed.  One  of  the  most  common  and,  at  the  same  time,  least  serious, 
consists  in  a  hard  oedema  limited  to  that  portion  of  the  prepuce  corre- 
sponding to  the  frainum,  and  which  may  be  very  persistent.  In  other 
patients,  the  edges  of  the  opening  of  the  abscess  become  indurated  and  it 
becomes  difficult  to  uncover  the  glans.  Finally  in  persons  predisposed  to 
phimosis,  there  remains  a  narrowness  of  the  preputial  orifice  or  an  indura- 
tion of  the  whole  membrane"  (Hardy). 

Treatment — The  treatment  of  gonorrhoeal  lymphangitis  consists  in  rest 
in  the  horizontal  posture,  elevation  of  the  genitals,  full  baths,  local  bathino- 
witli  hot  water  and  incision  of  any  abscess  as  soon  as  formed.  Rules  for 
treatment  in  cases  of  phimosis  have  already  been  given. 

Adknitis — It  is  rare  to  observe  anything  more  serious  in  the  inguinal 
ganglia  in  cases  of  gonorrhoea,  than  slight  enlargement  and  tenderness, 
which  disappear  in  a  few  days.  According  to  the  statistics  of  the  Anti- 
quaille  Hospital  at  Lyons,  an  attendant  bubo  is  met  with  in  only  one  out 
of  every  fourteen  cases  of  gonorrhoea.^  It  is  at  once  recognized  by  the 
physician  and  patient  by  the  enlargement  and  tenderness  of  one  or  more 
glands  in  the  groin,  and  it  may  occasion  considerable  pain  and  uneasiness 
in  walking  and  standing.  Buboes  attendant  upon  gonorrhoea,  uncompli- 
cated with  chancroid,  are  "simple"  buboes;  of  which  a  fuller  description 
will  be  given  hereafter,  when  speaking  of  buboes  in  general.  They  may 
generally  be  made  to  disappear  in  a  few  days  by  keeping  the  patient  quiet 
and  producing  a  little  counter-irritation  by  painting  the  skin  over  them 
daily  with  tincture  of  iodine.  It  is  only  in  scrofulous  subjects,  or  in  con- 
sequence of  violence,  excessive  fatigue  or  general  depressing  influences, 
that  they  ever  exhibit  a  tendency  to  sujtpurate.  I  have  known  of  one 
instance  of  a  man  suffering  from  gonorrlnea,  without  the  slightest  trace  of 
venereal  ulceration,  who  after  exposure  to  great  hardship  upon  a  wreck, 
had  a  suppurating  bubo  that  confined  him  to  his  bed  for  six  months. 

'  Gaz.  d.  h6p.,  Paris,  No.  141,  18G1. 


130  SWELLED    TESTICLE. 


CHAPTER    X. 
SWELLED    TESTICLE. 

The  most  frequent  complication  of  gonorrhoea  is  an  affection  of  the 
scrotal  organs,  variously  known  by  the  names  of  swelled  testicle,  hernia 
humoralis,  orchitis,  and  by  the  more  correct  term,  gonorrheal  epididymitis. 
In  order  to  understand  the  mode  in  which  this  complication  supervenes 
upon  gonorrhoea  it  is  desirable  to  recall  to  mind  the  canal  Avhich  connects 
the  testicle  and  the  urethra,  and  which  is  designed  for  the  passage  of  the 
seminal  fluid.  Tracing  this  canal  from  before  backwards,  we  have  first  the 
aperture  of  the  ejaculatory  duct,  near  the  anterior  extremity  of  the  veru 
montanum  in  the  prostatic  portion  of  the  urethra ;  following  this  duct,  we 
find  that  it  merges  into  the  vas  deferens,  which  passes  round  the  bladder, 
through  the  spermatic  canal  in  the  abdominal  muscles,  and  finally  descends 
within  the  scrotum,  where  it  terminates  in  the  numerous  and  intricate  con- 
volutions of  the  epididymis.  We  thus  have  a  passage,  lined  with  mucous 
membrane,  which  is  continuous  w^ith  the  mucous  membrane  of  the  urethra, 
and  connects  the  deepest  portion  of  this  canal  with  the  epididymis. 

In  the  early  stages  of  urethral  gonorrhoea,  the  inflammation  is  generally 
confined  to  the  neighborhood  of  the  fossa  navicularis.  At  a  later  period, 
however,  the  deeper  portions  of  the  canal  are  involved,  and  the  disease 
may  thus  gain  access  to  the  ejaculatory  duct,  and,  under  the  influence  of 
any  exciting  cause,  extend  along  tlie  spermatic  canal  to  the  epididymis, 
or  even  beyond  this,  to  the  testicle  and  the  tissues  which  envelop  it.  The 
patient's  own  sensations  will  sometimes  indicate  that  in  this  mode  has 
originated  the  affection  of  the  testicle.  He  has  felt  a  dull  pain  in  the  peri- 
nteum  and  in  the  groin,  along  the  course  of  the  spermatic  vessels,  for  a  day 
or  two  before  he  observed  the  tenderness  and  swelling  of  the  testis.  Again, 
in  some  cases,  we  find  additional  evidence  of  the  same,  in  the  fact  that  the 
cord  corresponding  to  tbe  inflamed  testicle  can  be  felt  externally  to  be 
swollen  and  liard,  and  can  be  traced  from  the  testicle  through  the  inguinal 
canal,  even  into  the  iliac  fossa.  Post-mortem  examinations,  also,  have  ex- 
hibited the  ordinary  appearances  of  inflammatory  action  throughout  the 
whole  of  the  canal  connecting  the  testicle  and  urethra.  There  can  be  but 
little  doubt,  therefore,  that,  in  some  instances,  swelled  testicle  owes  its 
origin  to  the  extension  of  the  inflammation  along  a  continuous  mucous 
surface. 

This  explanation,  however,  will  not  account  for  all  nor  even  the  majority 
of  cases,  for  in  most  instances  there  is  no  evidence  whatever  that  the  cord 


CAUSES.  131 

has  beon  involved.^  Moreover  epididymitis  may  occur  before  the  disease 
has  reached  the  prostatic  urethra.  Again,  there  is  another  question  which 
comes  up  here  for  explanation  :  Why  is  it  that  the  uretliral  discharge  com- 
monly ceases  or  at  least  diminishes  on  the  occurrence  of  the  epididymitis  ? 
It  must  be  acknowledged  that  as  yet  no  satisfactory  solution  of  this  problem 
has  been  reached. 

"  Sympathy,"  "  metastasis,"  and  "  reflex  irritation"  (Brown-Sequard) 
have  been  adduced  in  explanation,  but  they  do  not  explain  tlie  facts  nor 
can  they  satisfy  the  mind  of  the  inquirer.  Further  progress  in  our  know- 
ledge of  the  nervous  system  may  throw  light  on  the  subject,  but  this  end 
has  not  yet  been  reached.  The  fact  is,  w^e  know  nothing  about  it,  and  we 
do  not  propose  to  enter  into  speculations.^ 

In  this  connection,  a  case  reported  by  Mr.  Furneaux  Jordan^  comes  in, 
in  which  inflammation  travelled  in  the  opposite  direction,  viz.,  from  the 
epididymis  to  the  urethra.  The  patient  received  a  severe  blow  on  the 
scrotum,  and  the  left  epididymis  was  found  to  be  enlarged,  painful  and 
tender.  Inflammation  extended  up  the  cord  into  the  ring,  followed  by  a 
slight  urethral  discharge  and  all  the  symptoms  of  a  mild  urethritis. 

Causes — Gonorrhoea  of  the  urethra  is  the  only  form  of  gonorrhoea  that 
gives  rise  to  swelled  testicle,  which  is  never  met  with  as  a  complication  of 
balanitis. 

The  following  table,  drawn  up  by  M.  de  Castelnau,*  exhibits  the  times 
of  its  appearance  in  the  course  of  the  gonorrhoea,  in  239  cases,  collected 
from  different  sources  : — 

AUBRET.  DbCASTELNAU.  TotAL. 

3  16 

7  34 

8  24 
6  39 
5  54 

8  72 

37  239 

In  the  experience  of  most  surgeons,  swelled  testicle  is  even  rarer  durino- 
the  first  fortnight  of  a  goiiorrlura,  than  would  appear  from  the  above  sta- 
tistics. As  a  general  rule,  it  may  be  said  to  supervene  after  the  third  week, 
and  most  frequently  after  the  sixth  week. 

Cases  are  reported  in  which  it  has  occurred  after  the  discharge  had  en- 
tirely disappeared,  and  in  one  as  late  as  three  months.  A  jiatient  once 
came  to  me  with  swelled  testicle,  five  weeks  after  I  had  treated  him  for 
a  clap,  and  had  dismissed  him  as  cured,  and  he  assured  me  that  he  had  not 

'  Out  of  346  cases  of  epididymitis,  Berg,  of  Copenhagen,  found  the  cord  involved 
in  only  182.  Jahresb.  ii.  d.  Leistung.  u.  Fortschr.  d.  ges.  Med.,  Berlin,  1868 
p.  588. 

*  For  a  specimen  of  the  bosh  that  may  be  written  on  this  subject,  the  reader  is 
referred  to  Tlie  Practitioner,  London,  Nov.  1878,  p.  345. 

3  Jr.  Brit.  M.  Ass.,  Aug.  1871. 

*  Ann.  d.  mal.  de  la  i»eau  et  do  la  syph.,  Paris,  Mai,  1844. 


1st  week 

2d      " 

3d      " 

4th    " 

5  th    " 

6th    " 

and  later 

Total 

Gaussail. 

Despine. 

AUBRE 

3 

2 

8 

4 

6 

17 

5 

2 

9 

16 

2 

15 

39 

2 

8 

6 

15 

43 

73 

29 

100 

132  SWELLED    TESTICLE. 

perceived  any  discharge  in  the  moanwliile,  nor  could  I  discover  any  upon 
examining  the  penis.  It  is  probable,  as  stated  by  Velpeau,  that  in  these 
cases  there  still  remains,  in  the  {)rostatic  portion  of  the  urethra  or  at  the 
neck  of  the  bladder,  a  small  amount  of  inflammation,  but  not  sufficient  to 
manifest  itself  externally. 

Instances  are  recorded  in  which  the  swelling  of  the  testicle  is  said  to 
have  ai)peared  before  the  discharge  from  the  urethra.  In  one  case  reported 
by  M.  Castelnau,  the  epididymitis  was  develo})ed  a  week  after  coitus,  and 
the  urethral  running  was  first  seen  five  days  afterwards.  M.  Vidal  {Ann. 
de  chir.,  1844)  gives  a  similar  case,  and  Yelpeau  {Diet,  de  med.,  art.  Tes- 
ticule)  admits  such  an  occurrence.  Dr.  Fred.  R.  Sturgis  {Med.  Rec,  N.  Y. 
Oct.  9,  1875)  also  reports  a  case  in  which  the  epididymitis  is  said  to  have 
appeared  on  the  tenth  day  after  exposure,  with  no  discharge  from  the  ure- 
thra until  five  days  afterwards.  It  is  not  improbable  that  a  gonorrhoea 
really  existed,  but  was  overlooked,  in  these  cases ;  still  it  is  by  no  means 
impossible,  especially  with  the  knowledge  we  now  possess  of  the  efif'ects  of 
immoderate  sexual  indulgence,  that  the  prostatic  portion  of  the  urethra 
alone  received  the  irritation  from  coitus,  and  that  the  effect  produced  was 
insufficient  to  manifest  itself  by  a  discharge  until  after  the  swelling  of  the 
testicle  had  taken  place. 

In  some  instances  we  are  able  to  trace  an  attack  of  swelled  testicle  di- 
rectly to  some  exciting  cause,  which  has  aggravated  the  urethral  disease. 
Thus  the  patient  may  have  been  imprudent  in  exercising  or  in  exposing 
himself  to  cold,  or  he  may  have  indulged  in  a  debauch  or  in  sexual  inter- 
course. Strongly  irritant  injections,  or  any  violence  done  to  the  canal  by 
a  large  bougie,  or  by  forcible  distention  when  using  a  syringe,  may  also 
occasion  it.  One  of  the  most  severe  cases  of  this  disease  that  I  ever  met 
with  had  been  induced  by  the  forcible  introduction  of  a  large  bougie  in  the 
treatment  of  a  gleet  of  several  years'  duration.  In  other  instances,  how- 
ever, the  exciting  cause  of  ej)ididymitis  is  not  apparent,  independently  of 
the  fact  that  the  inflammatory  action  has  had  time  to  involve  the  prostatic 
portion  of  the  urethra  and  gain  access  to  the  spermatic  ducts.  It  has  been 
supposed  by  some  surgeons,  that  the  use  of  copaiba  and  cubebs  is  occjvsion- 
ally  the  cause  of  epididymitis  ;  while  others  have  not  only  denied  this,  but 
have  even  recommended  these  drugs  in  the  treatment  of  this  affiection.  I 
have  already  referred  to  this  subject  in  speaking  of  the  anti-blennorrhagics, 
and  will  only  say  at  present  that  evidence  is  wanting  in  favor  of  both  these 
assertions.  We  have  no  reason  to  believe  that  co[)aiba  and  cul)ebs  ever 
occasion  this  disease,  and  still  less  reason  to  believe  that  they  can  be  used 
with  benefit  in  its  treatment. 

Epididymitis  may  also  be  caused  by  the  presence  of  urethral  stricture ; 
by  a  stone  in  the  bladder  or  the  lodgment  of  a  small  calculus  or  fragment 
of  stone  in  the  prostatic  urethra;  in  fact  by  any  irritation  set  up  in  the 
prostatic  sinus;  and  I  have  met  with  a  few  cases  in  which  the  only  exciting 
cause  has  appeared  to  be  exposure  to  cold.  Mr.  Samuel  Osborn'  reports 
two  cases  of  epididymitis  in  boys,  due  to  pressure  of  a  truss. 

»   Lancet,  Lond.,  July  13,  1878. 


SEAT.  133 

It  should  not  be  forgotten  that  wearing  a  well-fitting  suspensory  bandage 
during  an  attack  of  gonorrha'a  is  the  best  protection  against  swelled  testi- 
cle. The  patient  is  thus  relieved  of  the  weight  of  the  scrotal  organs,  the 
flow  of  blood  from  the  part  is  facilitated,  and  the  liability  to  inflammatory 
action  is  consequently  much  diminished. 

Seat Gonorrhoea!  epididymitis  more  frequently  attacks  the  left  testi- 
cle than  the  right.  Of  1342  cases  observed  by  Prof.  Sigmund,  of  Vienna, 
the  left  testicle  was  affected  in  two  thirds.^  The  greater  frequency  of  this 
disease  on  the  left  side  has  been  attributed  by  some  authors  to  the  fact 
that  men  usually  '*  dress"  on  this  side,  and  that  the  left  testicle  consequent- 
ly receives  less  support  than  the  right.  This  explanation,  however,  is 
very  questionable.  The  difference  is  doubtless  to  be  found  in  that  cause, 
as  yet  not  explained  in  a  perfectly  satisfactory  manner,  which  renders  the 
left  testicle  more  prone  than  the  right  to  take  on  various  forms  of  morbid 
action.  Both  testicles  rarely  become  inflamed  simultaneously.  Osborn 
(op.  cit.)  thinks  the  reason  why  only  one  testis  becomes  affected  at  one 
time,  to  be  that  the  congestion  caused  by  the  inflammation  occludes  the 
adjacent  opening  of  the  vas  deferens  on  the  other  side.  Not  unfrequently 
one  testis  is  attacked  after  the  other.  This  usually  occurs  only  after  the 
lapse  of  several  weeks,  though  I  have  seen  the  two  attacks  separated  by 
only  a  few  days'  interval.  Sigmund  states  that  both  testicles  were  affected 
in  seven  per  cent,  of  his  hospital  patients,  and  in  five  per  cent,  of  his  pri- 
vate cases.  Occasionally,  the  inflammation,  after  leaving  one  testicle  and 
attacking  the  other,  will  return  to  the  first  ;  to  this  form  of  the  disease 
Ricord  lias  given  the  expressive  name  of  see-saw  epididymitis. 

It  is  the  epididymis,  of  all  the  scrotal  organs,  which  is  first  and  chiefly 
involved  in  most  cases  of  this  disease.  It  is  here  that  the  vas  deferens  ter- 
minates, and  we  may  suppose  that  the  inflammatory  action  is  retarded  in 
its  progress  by  the  innumerable  and  intricate  convolutions  which  compose 
this  appendage  to  the  testicle.  At  an  early  stage  of  the  inflammation,  and 
also  after  the  swelling  has  somewhat  subsided,  the  epididymis  can  be  felt 
enlarged  to  several  times  its  natural  size.  The  normal  position  of  the 
epididymis  is  posterior  and  external  to  the  body  of  tlie  testicle,  and  pres- 
sure upon  this  part  excites  more  pain  than  elsewhere.  The  epididymis, 
not  being  enveloped,  like  the  testicle,  in  a  fibrous  capsule,  is  susceptible  of 
an  indefinite  amount  of  tumefaction,  and  frequently  enlarges  to  such  an  ex- 
tent as  to  ]»artially  surround  and  encase  the  body  of  the  testis. 

It  siiould  be  reco!le(rted,  however,  that  the  position  of  the  epididymis, 
relative  to  the  testicle,  may  be  abnormal ;  in  which  case  the  seat  of  the 
greatest  tenderness  and  swelling  will  diflPer  from  the  description  just  now 
given.     Such  malpositions  are  called  by  the  French  inversions  du  testicule, 

'  Brit,  anrf  For.  M.-Cliir.  Rev.,  Lond.,  Oct.  IS.'iG.  Mr.  Curlinj^  (Diso.ases  of  tlie 
Testis,  4  ed.  1878,  p.  2(j7),  gives  138  cases,  seventy-three  observed  by  Gaiissail, 
twenty-nine  by  D'Kspine,  and  thirty-six  occurring  in  his  own  practice,  iu  the  ma- 
jority of  wliich  the  riglit  testicle  was  aiTected. 


134  SWELLED    TESTICLE. 

They  have  been  thorouglily  investigated  by  M.  Eugene  Royet/  who  admits 
the  five  following  varieties: — 

1.  The  epididymis  may  be  anterior  to  tlie  body  of  the  testicle. 

2.  It  may  be  on  one  side,  either  the  external  or  internal. 

3.  It  may  be  superior  ;  the  long  axis  of  the  testis  being  antero-posterior, 
and  the  epididymis  resting  upon  its  upper  surface. 

4.  In  the  fourth  variety,  the  epididymis  and  vas  deferens  form  a  loop  or 
sling,  which  surrounds  the  testis  from  before  backwards. 

0.  In  the  fifth  variety,  the  relative  position  of  the  epididymis  and  testis 
varies  from  day  to  day,  without  appreciable  cause. 

All  these  varieties  are  rare,  with  the  exception  of  the  first,  which,  ac- 
cording to  Royet's  researches,  is  met  with  in  one  out  of  every  fifteen  or 
twenty  persons.  The  abnormal  position  of  the  epididymis  in  front  of  the 
testicle  is,  therefore,  the  only  one  possessing  much  practical  importance. 
The  possibility  of  this  malposition  should  be  borne  in  mind  both  in  ope- 
rating for  hydrocele  and  when  forming  a  diagnosis  of  scrotal  tumors.  In 
cases  of  epididymitis,  when  the  inflammation  is  not  general,  the  epididy- 
mis may  be  recognized  by  its  hardness  to  the  touch  and  its  sensibility  to 
pressure.  When  all  the  scrotal  organs  are  involved  in  the  inflammatory 
process,  Royet  states  that  the  chief  means  of  recognizing  an  anterior  posi- 
tion of  the  epididymis  are,  a  want  of  mobility  in  the  skin  anteriorly,  owing 
to  its  adhesion  at  this  point  to  tlie  epididymis,  and  the  fact  that  the  vas 
deferens  can  be  felt  in  front,  instead  of  behind  the  other  vessels  of  the 
cord. 

Next  to  the  epididymis,  the  tunica  vaginalis  is  most  frequently  involved 
in  gonorrhceal  epididymitis.  M.  Rochoux  has  advanced  the  idea  that  in- 
flammation of  this  membrane  is  the  chief  and  constant  lesion  in  swelled 
testicle  f  but  this  is  a  mistake.  A'^aginalitis,  although  a  very  frequent,  is 
not  a  constant  symptom,  and  is  always  consecutive  to  the  inflammation  ©f 
the  epididymis.  There  is  commonly  an  effusion  varying  in  quantity  and 
character,  within  the  tunica  vaginalis.  This  may  consist  only  of  serum 
and  be  a[)parently  due  to  simple  obstruction  of  the  circulation  ;  or  it  may 
contain  fibrin  and  other  products  of  inflammation.  Sometimes  bands  of 
lymph  bind  the  two  opposed  surfaces  together,  as  in  pleurisy.  The  sub- 
scrotal  cellular  tissue  also  participates  in  the  inflammatory  action,  and  is 
thickened  by  ojdema  or  fibrinous  deposit.  The  frequency  with  which  the 
tunica  vaginalis  is  involved  in  swelled  testicle,  while  the  body  of  the  tes- 
ticle is  unaffected,  lias  been  explained  by  Gendrin,^  who  states  that  when 
the  cellular  tissue  of  an  organ  is  continuous  with  that  underlying  a  neigh- 

1  De  I'inversion  du  testicule ;  Paris,  1859,  p.  55. 

2  Du  sifege  et  de  la  nature  de  la  maladie  improprement  appellee  orcliite  bleunor- 
rhagiqiie,  Arch.  gen.  demed.,  1833,  t.  ii,  p.  51. 

3  Histoire  anatomique  des  inflammation,  t.  i,  p.  143.  Curling,  op.  cit.,  p.  252, 
expresses  the  opinion  that  the  inflammation  seldom  passes  to  the  testicle,  and 
quotes  from  Hardy,  who  professes  to  have  found  the  testicle  involved  only  nine 
times  in  226  cases  of  gonorrhoeal  epididymitis,  an  experience  not  at  all  in  accord- 
ance with  our  own. 


SYMPTOMS.  135 

boring  serous  membrane,  it  becomes  a  ready  means  of  communicating  in- 
flammatory action ;  but  wben  a  contiguous  organ  is  not  thus  connected 
with  the  original  seat  of  the  disease,  the  passage  of  the  inflammation  is 
less  easy.  The  connecting  link  between  the  epididymis  and  tunica  vagi- 
nalis is  found  in  the  areolar  tissue  which  penetrates  the  former  and  under- 
lies the  latter,  while  the  testicle  is  surrounded  by  the  fibrous  tunica  albu- 
ginea,  and,  being  thus  isolated,  generally  escapes. 

Following  the  tunica  vaginalis  in  the  order  of  frequency,  the  spermatic 
cord  is  next  found  to  be  the  seat  of  inflammatory  action  in  gonorrhoeal 
epididymitis.  The  body  of  the  testicle  is  rarely  affected;  and  even  when 
involved,  the  fibrous  tunic  which  invests  it  limits  the  amount  of  swelling 
of  which  it  is  capable,  although  it  greatly  increases  the  suffering  of  the 
patient  by  constricting  the  inflamed  tissues. 

Some  idea  of  the  comparative  frequency  with  which  the  different  tissues 
now  mentioned  are  attacked  in  this  disease  may  be  formed  from  the  sta- 
tistics of  Prof.  Sigmund,  already  referred  to.  In  1342  cases,  the  epididy- 
mis was  alone  affected  in  61 ;  the  epididymis  and  tunica  vaginalis  in  856; 
the  epididymis  and  cord  in  108,  and  these  three  parts  together  in  317. 

The  propriety  of  the  name,  gonorrhoeal  epididymitis,  will  now  be  evi- 
dent. It  is  no  objection  to  this  term  that  the  epididymis,  in  many  cases, 
is  not  the  only  part  involved.  As  in  diseases  of  the  eye,  we  call  a  certain 
inflammation  iritis,  thougli  otlier  parts  besides  the  iris  are  involved,  so  in 
swelled  testicle,  tlie  principal  seat  of  the  disease  should  determine  its  sci- 
entific name.  The  term  orchitis,  which  is  adopted  by  Yidal,  Velpeau, 
and  most  English  authors,  is  less  correct,  and  is  moreover  objectionable, 
because  it  is  calculated  to  confound  this  disease  with  that  affection  of  the 
testicle  which  is  produced  by  syphilis,  and  which  is  totally  distinct  in  its 
character  and  symptoms. 

Symptoms — There  are  generally  no  marked  premonitory  symptoms 
])receding  an  attack  of  swelled  testicle.  Sometimes,  however,  we  find  that 
the  patient  has  suffered  from  malaise  for  several  days ;  that  he  has  had 
slight  fever,  perhaps  a  chill,  and  a  dull  pain  or  heavy  sensation  in  the 
perinaenm,  cord,  and  scrotal  organs,  attended  with  a  frequent  desire  to  pass 
water.  His  attention  is  soon  attracted  to  the  testicle  by  pain,  felt  especi- 
ally on  motion,  and  on  examination  he  finds  this  organ  swollen,  and  tender 
on  pressure.  The  swelling  and  tenderness  rapidly  increase,  and  the  pain 
extends  to  the  corresponding  thigh,  to  the  groin,  and  to  the  lumbar  region. 
In  the  course  of  twenty-four  or  forty-eight  hours,  tiie  affected  side  of  the 
scrotum  may  have  attained  the  size  of  the  fist ;  tlie  skin  is  tense  and  in 
some  cases  of  a  dark  red  or  almost  purplish  line ;  the  pain  may  be  very 
severe,  especially  at  night,  preventing  sleep ;  the  least  pressure  upon  the 
part,  even  from  the  bedclothes,  is  almost  unendurable  ;  partial  ease  only 
can  be  attained  by  keeping  perfectly  quiet  in  the  horizontal  posture  with 
the  addition  of  some  support  to  the  genital  organs.  If  the  cord  be  involved 
the  pain,  swelling,  and  tenderness  are  found  to  extend  upwards  to  the  in- 
guinal canal.     The  cord  may  indeed  be  involved  alone  without  the  epidi- 


136  SWELLED    TESTICLE. 

dymis  being  affected.  The  possibility  of  this  was  denied  by  Ricord,  but 
Beaume  has  reported  several  and  Bergh  one  case  of  this  kind  (Zeissl). 
Kohn  also  mentions  it.^ 

There  is  generally  more  or  less  febrile  disturbance  of  the  system  at 
large.  The  skin  is  hot,  the  tongue  coated,  the  pulse  increased  in  force  and 
frequency,  and  the  patient  extremely  nervous  and  agitated.  Cases  are 
reported  in  which  the  swelling  of  the  cord  was  so  excessive  as  to  produce 
strangulation  at  the  abdominal  ring,  attended  by  symptoms  resembling 
those  of  strangulated  hernia,  such  as  abdominal  tenderness  and  vomiting. 
It  must  not  be  supposed,  however,  that  the  symptoms  are  always  so  severe 
as  those  now  described.  Such  severity  is  more  apt  to  be  met  with  in 
persons  of  a  nervous  temperament,  in  whom  this  disease  is  one  of  the  most 
distressing  that  can  occur.  In  other  cases,  however,  the  sutfering  is  com- 
paratively slight,  and  I  have  known  patients  to  attend  to  their  daily 
occupation  during  its  whole  course.  Between  these  two  extx-emes  we  may 
have  every  shade  of  variation. 

While  the  inflammation  is  at  its  height  it  is  impossible  to  distinguish 
the  different  portions  of  the  scrotal  organs.  Judging  from  mere  inspection 
of  the  swelling,  we  might  be  led  to  suppose  that  it  was  chiefly  made  up  of 
the  body  of  the  testicle.  This,  however,  is  not  so.  It  is  composed,  for  the 
most  part,  of  the  swollen  epididymis,  of  an  effusion  into  the  tunica  vagina- 
lis, and  of  oedema  of  the  subscrotal  cellular  tissue.  The  hydrocele  is  often, 
but  not  always,  sufficient  to  enable  us  to  detect  distinct  fluctuation,  and 
rarely,  if  ever,  is  the  tumor  transparent;  but  on  gently  touching  it,  the 
surface  is  found  to  yield  for  a  short  distance  before  the  fingers  come  in  con- 
tact with  the  firmer  body  of  the  testicle  beneath.  This  yielding  is  due  to 
the  displacement  of  the  oedema  of  the  scrotum  and  of  the  fluid  in  the  sac. 
If  the  tumor  be  punctured  with  a  lancet,  bloody  serum,  varying  in  amount 
from  a  few  drops  to  several  drachms,  will  escape. 

Resolution  begins  to  take  place  in  a  few  days,  commencing  in  the  ante- 
rior portion  of  the  tumor.  The  oedema  of  the  scrotum  and  the  hydrocele 
disappear,  and  the  different  portions  of  the  testis  can  now  be  distinguished 
from  each  other — the  epididymis,  still  swollen  and  hard,  behind  ;  and  the 
body  of  the  testicle,  preserving,  in  most  cases,  its  normal  elasticity,  in  front. 
The  whole  duration  of  the  attack  varies  from  one  to  three  weeks.  In  a 
discussion  on  the  treatment  of  this  disease  before  the  Academy  of  Medicine 
in  Paris,  in  1854,  Velpeau  stated  that  its  duration  under  ordinary  methods 
of  treatment  averaged  10  to  18  days. 

In  some  cases  of  swelled  testicle,  after  the  more  acute  symptoms  have 
subsided,  the  parts  still  remain  engorged  and  the  disease  shows  a  tendency 
to  become  chronic.  This  is  most  likely  to  occur  in  patients  of  weak  habit, 
and  while  this  condition  lasts  the  least  exciting  cause  may  induce  a  return 
oi"  the  acute  inflammation. 

Most  cases  of  swelled  testicle  terminate  fiivorably.  In  some  rare  instances, 
however,  abscesses  form  in  the  cellular  tissue  underlying  the  sci'otum,  or 

'  See  Am.  J.  Sypli.  and  Derm.,  N.  Y.,  vol.  ii,  p.  165. 


SYMPTOMS.  137 

in  the  epididymis  or  body  of  the  testicle.  Mr.  Edwards*  has  reported  a 
case  in  which  the  whole  testicle  protruded  through  an  opening  formed  by 
an  abscess  in  the  scrotum,  the  skin  being  drawn  in  around  the  orifice.  Mr. 
Edwards  "  pared  the  edges,  drew  them  asunder,  making  with  the  handle 
of  the  scalpel  a  sufficient  separation  of  the  deeper  tissues,  and  the  testicle 
was  at  once  drawn,  as  it  were,  back  into  the  scrotum,  the  wound  closing 
over  it.  Three  hare-lip  pins  were  inserted;  the  wound  closed  by  first 
intention,  and  the  patient  was  walking  about  perfectly  well  on  the  seventh 
day."  If  an  abscess  form  and  be  not  early  evacuated,  the  pus  generally 
burrows  in  various  directions,  forming  sinuses,  and  destroying  a  portion  of 
the  parenchyma,  but  the  loss  of  a  portion  of  the  organ  does  not  ai)pear  to 
be  followed  by  any  disturbance  of  its  function  ;  sometimes  a  circumscribed 
abscess  is  formed,  which  may  become  encysted,  and,  the  more  fiuid  portion 
being  absorbed,  the  solid  portion  may  remain  in  a  concrete  state  for  an  in- 
definite length  of  time,  and  closely  resemble  a  tubercular  deposit.  The 
presence  of  the  cyst  will  clear  up  the  diagnosis,  since  true  tubercular  matter 
is  always  found  in  direct  contact  with  the  parenchyma  of  the  testis,  and  is 
never  encysted. 

The  swelling  of  the  testicle  attendant  upon  gonorrhoea  may,  however, 
be  the  exciting  cause  of  true  tubercular  deposit,  in  persons  of  a  strumous 
diathesis.^ 

As  the  epididymis  was  the  first  part  attacked,  so  it  is  the  last  to  recover 
its  normal  condition,  and  in  some  cases  it  retains,  for  months  or  years,  an 
irregular  and  knotty  mass  of  induration,  which  may  obstruct  the  passage 
of  tiie  semen  and  render  the  affected  testis  useless.  If  this  induration  exist 
on  both  sides,  or  if  the  opposite  testicle  be  undeveloped,  as  is  often  the  case 
with  an  undescended  testis,  the  patient  will  probably  be  impotent.  In  a 
few  rare  cases  gonorrhceal  epididymitis  has  been  known  to  terminate  in 
atrophy  of  the  testicle.  Hypertrophy  is  extremely  rare,  but  is  sometimes 
seen  in  persons  who  have  had  frequent  attacks  of  swelled  testicle. 

The  reflex  neuralgias  which  not  infrequently^  complicate  cases  of  gonor- 
rhoea! epididymitis  have  been  admirably  described  by  Mauriac  in  a  pam- 
phlet entitled  Etude  svr  les  vevralgies  reflexes  syivptomatiqnes  deVorchi- 
epididymite  blennon-hagique,  Paris,  1870,  which  is  well  worthy  of  perusal. 

In  the  majority  of  cases  the  pain  is  unilateral  and  is  confined  to  the 
sphere  of  distribution  of  the  lumbar  and  sacral  nerves  upon  the  same  side 
as  the  affected  testicle.  At  other  times,  the  pains  radiate  in  various  direc- 
tions, cross  the  median  line  and  extend  far  beyond  the  limits  above  men- 
tioned. 

The  pains  in  the  spine  appear  to  have  their  focus  at  a  point  correspond- 
ing to  the  anastomosis  of  the  lumbar  with  the  sacral  plexus  of  nerves  ;  they 
may  be  bilateral  and  more  intense  on  the  side  opposite  the  epididymitis. 

'  Edinb.  M.  J.  Nov.  1800,  p.  455. 

^  A  case  of  this  kind  was  recently  exhibited  at  a  meeting  of  the  Anatomical  Society 
of  Paris.     Bull.  Soc.  anat.  de  Paris,  2d  s^rie,  t.  iv,  p.  2. 

'  In  200  cases  of  epididymitis  Mauriac  found  15  with  very  decided  rellex  pains. 


138  SWELLED    TESTICLE. 

Some  patients  feel  as  if  the  pain  started  from,  others  that  it  terminated  at, 
this  point. 

Sometimes  the  whole  of  tlie  lumbar  region  from  the  ribs  to  the  sacrum, 
is  the  seat  of  dull  pain,  or  the  latter  is  felt  deeply  in  the  region  of  the  kid- 
ney ;  this  being  due  to  reflex  manifestations  in  tlie  plexus  of  the  grand 
sympathetic.  From  the  lumbo-sacral  focus  the  pain  radiates  to  the  abdo- 
men and  the  lower  extremity.  The  abdominal  pains,  which  are  almost  as 
common  as  the  lumbar,  sometimes  feel  like  a  constricting  belt  encircling 
the  body  beneath  the  umbilicus.  Most  frequently  they  do  not  cross  the 
median  line.  They  are  superficial  and  are  relieved  rather  than  exasperated 
by  pressure. 

The  walls  of  the  thorax  are  sometimes  involved,  and  a  vague  aching 
sensation  is  felt  at  a  fixed  point  with  radiations  along  the  course  of  the 
intercostal  nerves. 

The  sympathetic  pains  which  extend  to  the  lower  extremity  on  the  affect- 
ed side,  may  be  divided  into  two  groups,  an  anterior  or  crural  and  a  pos- 
terior or  sciatic.  The  anterior  group  may  occupy  two-thirds  or  even  the 
whole  of  the  antero-internal  surface  of  the  thigh,  and  it  is  then  difficult  to 
say  exactly  what  nerves  are  invaded.  Below  the  knee,  the  internal  sa- 
phena,  the  fourth  terminal  branch  of  the  crural  nerve,  is  the  one  evidently 
involved. 

As  regards  the  posterior  group,  we  often  find  the  pains  limited  to  the 
buttocks  and  to  the  postero-external  portion  of  the  thigh.  They  are  gene- 
rally most  marked  over  the  upper  part  of  the  sciatic  notch  behind  the 
great  trochanter,  towards  the  middle  of  the  thigh  behind  and  in  the  pop- 
liteal space. 

The  characteristics  of  these  reflex  neuralgias  are  precisely  similar  to 
those  of  the  direct  neuralgias.  In  their  intensity  they  vary  greatly.  Some- 
times they  become  intolerable  from  their  sharpness,  their  frequency  and 
their  extension  to  all  the  branches  of  the  nerves  which  emanate  from  the 
lumbar  and  sacral  plexus.  The  whole  side  of  the  body  corresponding  to 
the  affected  testicle  may  be  the  seat  of  agony.  There  follow  insomnia, 
anxiety,  and  general  nervous  excitement  which  sometimes  rises  to  the  point 
of  hysteriform  spasm.  Patients  will  cry  out  with  the  pain.  They  try  to 
calm  it  by  bending  the  trunk  towards  the  thighs  or  by  pressing  upon  the 
more  painful  points;  it  is  not,  however,  usual  to  find  those  painful  foci  of  the 
disease  so  much  insisted  upon   by  Valleix  as  a  characteristic  of  neuralgia. 

The  duration  of  these  pains  is  very  variable,  extending  from  twenty- 
four  hours  as  a  minimum  to  several  months.  Those  situated  in  the 
branches  of  the  lumbo-sacral  nerves  are  much  more  persistent  than  those 
which  appear  to  have  their  seat  in  the  sympathetic,  and  among  the  former 
those  which  radiate  towards  the  testicle  will  commonly  be  found  to  be  the 
most  lasting. 

When  appearing  in  the  form  of  paroxysmal  attacks,  these  pains  have  no 
regularity,  and  occur,  as  they  also  disappear,  without  consulting  the  clock. 
Their  termination  is  always  favorable,  if  we  except  the  fact  that  their  con- 


SYiMPTOMS  139 

tinuance  is  liable  to  keep  up  the  engorgement  of  the  epididymis  (which 
the  cause  and  which  the  effect?). 

It  may  here  be  remarked  in  advance  of  the  treatment  of  gonorrhoea! 
epididymitis  that  Mauriac  speaks  highly  of  the  application  of  leeches  over 
the  cord,  as  well  as  of  puncture  of  the  tunica  vaginalis,  and  other  means 
to  be  mentioned  hereafter.  In  brief,  the  treatment  of  these  reflex  neural- 
gias is  the  treatment  of  the  exciting  cause. 

Zeissl  states  that  the  most  frequent  sequence  of  epididymitis  is  chronic 
hydrocele,  v/hich  we  have  often  had  occasion  to  observe.  Yetault^  claims 
that  this  affection  is  caused  by  pressure  of  the  products  of  inflammation 
thrown  out  in  the  head  of  the  epididymis  and  in  the  cord  upon  the 
vessels. 

Zeissl  states  as  a  result  of  his  experience,  that  those  men  who  have  had 
frequent  attacks  of  epididymitis,  are  most  prone  to  have  orchitis  in  case 
they  subsequently  contract  syphilis  (?). 

The  condition  of  the  urethral  discharge  preceding  and  during  an  attack 
of  swelled  testicle  has  been  the  subject  of  considerable  discussion.  It  was 
at  one  time  supposed  that  this  complication  of  gonorrhoea  was  usually  pre- 
ceded by  a  diminution  of  the  running,  and  hence  that  it  might  be  attributed 
to  the  use  of  active  measures  which  were  supposed  to  drive  the  disease  from 
the  urethra  to  the  testicle.  On  this  supposition  has  been  founded  the 
theory  tiiat  sw'elled  testicle  may  be  caused  by  metastasis.  A  proper  ap- 
preciation of  the  facts  in  the  case,  however,  does  not  warrant  this  conclu- 
sion. It  is,  indeed,  true  as  a  general  rule,  that  the  urethritis  has  passed 
the  acute  stage,  and  that  the  discharge  has  consequently  diminished  before 
the  epididymis  becomes  inflamed,^  but  this  is  the  natural  course  of  the 
disease  when  no  complication  whatever  takes  place.  To  prove  a  metastatic 
origin  of  the  epididymitis,  it  would  be  necessary  to  show  that  there  is  a 
sudden  disappearance  or  diminution  of  the  running,  just  preceding  the 
swelling  of  tlie  testicle  ;  such,  however  does  not  occur.  On  tlie  contrary, 
as  stated  by  Ricord,  there  is  often  an  exacerbation  of  the  urethral  disease 
and  a  slight  increase  of  the  discharge  for  a  day  or  two  preceding.  "When 
the  disease  of  the  testicle  is  fairly  established,  the  discharge  diminishes  as 
a  consequence  of  revulsive  action.  These  phenomena  coincide  witli  what 
is  seen  in  affections  of  other  paits  when  acute  inflammation  is  established 
in  their  neighborhood. 

Tlie  induration  of  the  epididymis,  which  frequently  remains  for  some 
time  after  an  attack  of  swelled  testicle,  or  which  may  even  become  per- 

'  Considerations  etiologiqiios  sur  I'hydrocele  des  adultes,  Paris,  1872. 

2  Gaussail's  statistics  rehitivt^  to  the  discharge  are  as  follows  :  In  G7  of  73  cases, 
the  discharge  and  the  otlier  symptoms  of  the  gouorrluca  had  diminished  more  or 
less — in  otlier  words,  the  acute  stage  of  clap  had  passed — when  the  swelling  of  the 
testicle  tgok  place  ;  in  6  cases,  tlie  gonorrhcBa  was  still  at  its  height. 

In  30  of  the  73  cases,  the  discharge  grailually  diminished  and  disappeared  en- 
tirely during  the  treatment  of  the  epididymitis  ;  in  43  cases,  some  discharge  re- 
mained after  the  disease  of  the  testicle  was  cured. 


140 


SWELLED    TESTICLE. 


Fiff.  38. 


manent,  requires  further  mention.     This  induration  is  commonly  situated 
in  the  lower  part  of  the  epididymis,  in  or  near  the  glohus  minor.     It  will 

be  recollected  that  the  upper  portion,  or 
globus  major,  is  composed  of  the  convo- 
lutions of  the  vasa  eff'erentia,  which  are 
from  ten  to  thirty  in  number,  but  that 
these  minute  vessels  unite  into  a  single 
duct,  before  leaving  this  portion.  Hence 
tlie  globus  major  of  the  epididymis  con- 
sists of  several  seminiferous  tubes,  any 
one  of  w'hich  would  be  sufficient  to  con- 
vey the  semen,  in  case  the  others  were 
obstructed  ;  while  the  body  and  globus 
minor  contain  but  one  tube,  the  oblitera- 
tion of  which  must  "  completely  cut  off 
the  communication  between  the  testis 
and  the  penis.  But  it  is  in  this  latter 
portion,  viz.,  the  globus  minor,  that  the 
induration  left  by  an  attack  of  swelled 
testicle  is  almost  invariably  found  ;  and, 
as  we  shall  presently  see,  it  generally  af- 
fects the  obliteration  of  the  single  duct 
of  the  part,  and  renders  the  patient  im- 
potent upon  the  affected  side. 

It  now  becomes  an  interesting  subject 
of  inquiry,  what  effect  this  obliteration 
has  upon  the  testis  ;  whether  it  remains  in  a  normal  condition,  and  con- 
tinues to  secrete  sperm.  Again,  in  those  cases  in  which  epididymitis  has 
occurred  on  both  sides,  an  induration  may  be  left  in  each  testicle,  totally « 
obstructing  the  passage  of  semen  ;  in  such  cases  does  the  patient  still  retain 
sexual  desires  ;  is  he  capable  of  sexual  intercourse  ;  and  if  so,  how  does  his 
semen  differ  from  that  of  a  perfectly  healthy  individual  ?  These  questions 
have  been  ably  answered  in  a  paper  by  Dr.  L.  Gosselin,  published  in  the 
Arch.  gen.  de  med.  for  Sept.  1853. 

Dr.  Gosselin's  conclusions  are  based  upon  experiments  upon  the  lower 
animals,  and  upon  the  observation  of  twenty  patients  affected  with  double 
induration  of  the  epididymis  following  gonorrliu'a.  The  spermatic  cord  of 
one  side  was  exposed  in  two  dogs,  the  vas  deferens  isolated  from  the  sper- 
matic vessels,  and  a  portion  of  it  excised.  The  animals  were  killed  several 
months  after,  when  it  was  found  that  the  testicle  of  the  side  opei'ated  on 
presented  the  same  volume,  color,  and  general  character  as  that  of  the  op- 
posite side;  the  only  difference  was  that  the  convolutions  of  the  epididymis 
in  the  former  were  distended  with  fluid,  containing  a  multitude  of  sperma- 
tozoa. Tlie  excision  of  a  portion  of  the  vas  deferens  had  completely  cut 
off  the  communication  with  the  penis-  These  experiments  proved  that 
isolation  of  the  testicle  in  the  lower  animals  does  not  produce  atrophy  of 


Vertical  section  of  the  testis  and  epidi 
dyinis.     (After  Gray.) 


SYMPTOMS.  I4l 

this  organ,  which  remains  in  an  apparently  healthy  condition,  and  continues 
to  secrete  semen. 

The  twenty  persons  who  had  had  double  epididymitis  were  met  with  at 
the  Hopital  du  Midi,  and  in  the  private  practice  of  Dr.  Gosselin.  The 
time  which  had  elapsed  since  the  formation  of  the  induration,  at  the  time 
of  the  observation,  varied  from  a  few  weeks  to  ten  years.  The  symptoms 
which  they  presented  were  in  some  I'espects  singular  and  remarkable.  In 
all  of  them  there  was  a  mass  of  induration  in  the  lower  portion  of  the  epi- 
didymis of  each  testicle.  In  none  of  them  was  there  any  apparent  change  in 
the  volume  of  the  scrotal  organs,  and  no  pain  was  felt  at  any  time,  not  even 
after  sexual  intercourse.  None  of  them  had  observed  any  change  in  their 
sexual  desires  or  powers.  They  were  all  as  capable  of  coitus  as  the  most 
healthy  individuals.  Their  erections  and  ejaculations  were  complete. 
Their  semen  was  normal  in  quantity,  in  consistency,  in  odor,  and  color ; 
it  presented  the  chemical  reactions  described  by  Berzelius,  as  characteristic 
of  sperm.  Only  when  examined  by  the  microscope,  was  it  found  to  differ 
at  all  from  healthy  semen,  inasmuch  as  it  was  entirely  destitute  of  sperma- 
tozoa. In  the  recent  cases,  most  of  which  were  still  aflected  with  urethritis, 
pus  and  blood-globules  were  found  mixed  with  the  semen  ;  in  the  older 
cases  these  were  absent.  The  entire  absence  of  spermatozoa  in  all  of  tliem 
was  confirmed  upon  repeated  examination  by  Drs.  Gosselin,  Robin,  Ver- 
neuil,  and  other  eminent  Parisian  microscopists.  In  two  of  these  cases, 
treatment,  continued  in  the  one  case  for  three  months,  and  in  the  other  for 
nine,  resulted  in  the  disappearance  of  the  induration  in  one  of  the  testicles, 
and  coincidently  with  this  resolution  spermatozoa  again  appeared  in  the 
semen,  as  shown  by  microscopical  examination. 

These  cases  are  of  the  highest  interest,  looking  at  them  both  in  the 
light  of  physiology,  and  of  pathology  and  therapeutics.  Tiiey  show,  in 
the  first  place,  tliat  the  quantity  of  fluid  ejaculated  is  as  abundant  and 
presents  the  same  general  appearances  when  the  canal  of  the  vas  deferens 
is  obliterated  as  when  it  is  free;  also,  that  in  case  of  obliteration,  the 
secretion  of  sperm  in  the  testis  is  not  sufficient  to  distend  the  vessels  to 
any  great  extent,  or  to  occasion  pain.  Probably  there  is  some  absorption 
of  the  secreted  sperm,  but  if  as  much  of  this  fluid  were  secreted  by  the 
testicles  as  is  commonly  supposed,  the  effect  upan  the  testicular  vessels 
and  upon  the  feelings  of  the  patient  would  be  more  manifest.  From  these 
facts  Dr.  Gosselin  concludes  that  the  normal  function  of  the  testicle  is  to 
furnish  the  fecundating  eh'ment  of  tlie  sperm,  viz.,  the  spermatozoa;  and 
that  the  other  components  of  the  spermatic  fluid,  to  which  it  owes  its 
color,  odor,  and  chemical  reactions,  and  which  constitute  the  medium  in 
which  the  spermatozoa  live,  are  derived  for  the  most  part  from  the  vesicukt 
seminales. 

But  the  conclusions  from  these  facts  which  chiefly  interest  us  at  the 
present  time  are  those  bearing  on  the  pathology  and  treatment  of  epididy- 
mitis.     These  conclusions,  as  stated  by  Dr.  Gosselin,  are  the  followino-: 

1.  The  induration  is  generally  situated  in  the  globus  minor  of  the 
epididymis,  though  it  may,  strictly  speaking,  be  seated  in  any  part  of  tliis 


142  SWELLED    TESTICLE. 

organ.  Since  the  epididymis  below  tliie  globus  major  is  composed  of  but 
a  single  vessel,  the  obliteration  of"  this  vessel  is  sufficient  to  prevent  the 
passage  of  the  s[)erm. 

2.  The  presence  of  the  induration  excites  no  pain,  provided  that  the 
inflammation  which  produced  it  has  entirely  subsided. 

3.  It  does  not  occasion  any  change,  appreciable  by  the  patient,  in  the 
exercise  of  the  genital  functions. 

4.  If  the  spermatic  vessel  be  obliterated  on  both  sides,  the  patient  is 
necessarily  impotent;  if  on  one  only,  fecundation  is  possible,  provided 
that  the  other  testicle  is  sound. 

5.  The  success  of  treatment  in  several  of  the  cases  reported  affords 
assurance  that  the  power  of  fecundation  may  sometimes  be  restored  by 
appropriate  remedies. 

Two  additional  cases  of  bilateral  induration  resulting  from  epididymitis 
have  been  reported  by  Gosselin,  which  confirm  his  previous  observations 
regarding  the  retention  of  virile  power  and  the  absence  of  spermatozoids 
from  the  fluid  emitted. 

M.  Godard  slates  that  he  has  confirmed  Gosselin's  observations  by 
microscopical  examination  of  the  semen  of  thirty-five  persons  affected  with 
double  chronic  epididymitis,  and  in  every  instance  except  one  spermatozoa 
■were  wanting.^ 

Liegeois"  gives  twenty-eight  cases  of  double  epididymitis,  in  the  sperm 
of  seven  of  which  the  microscope  showed  spermatozoids  at  periods  varying 
from  eight  days  to  five  years  after  the  last  attack.  Five  of  these  cases 
were  not  blennorrhagic,  leaving  two,  of  undoubted  venereal  origin,  in 
which  there  was  restoration  of  the  fecundating  elements. 

Liegeois  concludes  from  his  experience  that  s[)ermatozoids  reappear  in 
cases  of  blennorrhagic  epididymitis  only  after  the  disappearance  of  the 
induration,  which,  in  non-blennorrhagic  cases,  has  its  seat  outside  the  canal, 
and,  therefore,  may  persist  without  preventing  their  passage.  He  claims 
to  have  seen,  among  three  hundred  cases  of  epididymitis,  not  a  single 
genuine  case  of  consecutive  atropiiy  of  the  testicle,  although  he  has  recog- 
nized slight  diminution  in  volume  in  six  or  seven  instances.  In  only 
eight  cases  has  he  observed  any  loss  of  virile  power,  while,  on  the  con- 
trary, he  has  sev(?ral  times  seen  it  markedly  increased. 

He  calls  attention  to  the  fact  of  decided  increase  in  the  quantity  of 
ejaculated  fluid,  which,  as  observed  by  Gosselin,  presents  the  characters 
of  normal  sperm,  with  the  exception  of  the  spermatozoids,  and  is  probably 
derived  from  the  prostate  gland  and  the  seminal  vesicles. 

If  gonorrhceal  epididymitis  attack  a  testicle  which  has  been  arrested  in 
its  descent  from  tlie  abdomen  to  the  scrotum,  the  nature  of  the  case  may 
readily  be  mistaken.  If  the  testis  have  not  left  the  abdominal  cavity,  it 
may  simulate  peritonitis  or  iliac  abscess  ;  if  it  be  arrested  in  the  spermatic 

'  Etudes  snr  la  monorchidie  et  la  cryptorchidie  cliez  I'homme,  Mem.  Soc.  de 
biol.,  Par.  1857,  p.  105. 

2  Ann.  de  derm,  et  syph.,  Par.  18G9,  p.  410. 


PATHOLOGICAL    ANATOMY.  143 

canal,  it  may  counterfeit  strangulated  hernia  or  bubo  ;  and  the  liability 
to  error  is  especially  great,  when,  as  often  occurs,  the  tunica  vaginalis  is 
still  connected  with  the  abdominal  cavity,  and  true  peritonitis  is  set  up  by 
extension  of  the  inflammation,  attended  by  its  usual  alarming  symptoms. 
Numerous  cases  in  illustration  of  these  remarks  may  be  found  in  the  work 
of  INI.  Godard  before  referred  to. 

A  still  rarer  malposition  of  the  testicle  is  in  the  perinaeum  ;  an  anomaly 
first  observed  by  John  Hunter,^  who  met  with  two  instances.  Ricord  and 
YidaP  (de  Cassis)  have  each  observed  two  cases  ;  Mr.  Ledwich^  met  with 
one  in  a  dissecting  room  subject,  and  Godard*  gives  the  history  of  another, 
with  a  plate  of  the  abnormity.  A  perineal  testicle  affected  with  gonor- 
rho^al  epididymitis  may  simulate  a  perineal  abscess  or  inflammation  of 
Cow[)er's  glands,  as  in  the  two  instances  observed  by  Ricord.^  "  In  one, 
there  was  a  perineal  tumor,  which  was  exquisitely  painful,  fluctuating  and 
about  the  size  of  a  pigeon's  egg.  It  was  at  first  taken  for  an  abscess,  and 
Ricoi'd  was  about  to  open  it,  when  examination  of  the  scrotum  led  to  tiie 
discovery  that  one  testicle  was  absent." 

There  is  another  consideration  connected  with  abnormal  position  of  the 
testicle,  which  is  worthy  of  mention.  In  most  cases  of  this  anomaly,  the 
gland  is  useless  for  the  purposes  of  procreation.  According  to  Goubaux 
and  Follin,^  it  undergoes  fibrous  or  tatty  degeneration.  This  is  denied  by 
Godard,  who,  however,  has  equally  shown  that  the  gland,  as  a  general 
rule,  is  impotent,  by  microscopical  examination  of  the  contained  sperm  after 
death.  In  eight  cases  out  of  nine,  spermatozoa  were  wanting.  Now,  if 
the  anomaly  be  confined  to  one  side,  and  the  opposite  testicle  be  in  a  healthy 
condition,  fecundation  is  still  possible ;  but  if  the  descended  testicle  be 
attacked  by  epididymitis,  obliteration  of  its  vas  deferens  will  deprive  the 
patient  of  all  procreative  power,  as  in  the  cases  of  double  epididymitis 
observed  by  Gosselin.  Godard  gives  the  history  of  a  man  with  one 
undescended  testis,  who  had  a  child  by  a  mistress,  but  who,  after  an  attack 
of  swelled  testicle  on  the  opposite  side,  was  twice  married  without  progeny, 
and  his  semen,  twenty-one  years  afterwards,  was  found  destitute  of  sper- 
matozoa. 

Pathological  Anatomy Since  epididymitis,  when  uncomplicated, 

is  never  fatal,  opportunities  for  post-mortem  examination  are  rare,  and 
only  occur  in  case  some  intercurrent  disease  produces  tiie  death  of  the 
patient.  The  most  com[)lete  report  of  such  examination  with  which  I  am 
acquainted,  is  to  be  found  in  the  Gaz.  d.  hop.  for  Dec.  21,  1854. 

*  Curling,  op.  cit.,  p.  51. 

*  Traits  de  pathologic  externe,  t.  v,  p.  432. 
3  Dubl.  Q.  J.  M.  Sc,  Feb.  1855. 

<  GoDAKD,  op.  cit.,  p.  96.  5  Op.  cit.,  page  75,  and  plate  III. 

6  Foiling  Etudes  anat.  et  path,  sur  Ics  anomalies  de  position  et  les  atrophies  du 
testicule  ;  Arch.  gen.  de  med.,  Par.,  juillet,  1851,  p.  262. 

Gouii/Vux  ET  FoLLiN,  De  la  cryptorchidie  chez  I'homine  et  les  principaux  animaux 
domestiques  ;  Mem.  Soc.  de  biol.,  Par.  1855,  p.  317. 


144  SWELLED    TESTICLE. 

Case — The  patient  entered  Velpeau's  wards  at  la  C/'ar^Ve  with  swelled 
testicle,  of  eijjlit  days'  duration  ;  the  epididymis  was  situated  in  front  of  the 
testicle,  and  was  swollen  and  hard  ;  the  cord  was  also  involved,  while  the 
body  of  the  testicle  ap{)eared  to  be  sound,  and  there  was  no  effusion  in  the 
tunica  vaginalis. 

Eighteen  days  after  his  admission,  and  twenty-six  after  the  commence- 
ment of  his  attack,  this  patient  died  of  cholera.  The  post-moi'tem  was 
made  by  M.  Gosselin,  with  the  following  result : — 

1.  The  tunica  vaginalis  contained  no  fluid  and  was  free  from  injection 
of  its  vessels. 

2.  The  body  of  the  testicle  was  healthy. 

3.  The  globus  major  and  the  body  of  the  epididymis  were  also  healthy ; 
but  the  globus  minor  was  swollen  and  formed  a  hard,  uniform  mass,  the 
size  of  a  haricot  bean.  On  cutting  open  this  mass,  it  was  found  to  be  des- 
titute of  blood-vessels,  of  a  uniform  yellow  color,  resembling  tubercle,  and 
of  firm  consistency.  The  sections  of  the  convoluted  spermatic  duct  upon 
the  cut  surface  showed  that  this  vessel  had  attained  three  or  four  times  its 
natural  size,  and,  instead  of  being  hollow,  that  it  was  filled  with  uidform 
yelloiv  matter  :  there  was  none  of  this  matter  between  tite  convoluted  vessels  ; 
it  was  entirely  within,  and  in  the  substance  of  the  loalls.  M.  Robin  ex- 
amined this  matter  under  the  microsco|)e  and  found  pus-globules,  mixed 
with  fat-globules  and  the  granular  globules  of  inflammation.  He  also 
confirmed  the  statement  that  this  matter  was  limited  to  the  interior  of  the 
vessels. 

4.  The  vas  deferens,  which  had  recovered  its  normal  size,  was  filled  with 
yellowish  matter,  containing  no  spermatozoa,  and  composed  of  [)us-globules, 
cylindrical  epithelial  cells,  and  granular  corpuscles.  Its  walls  exhibited  a 
perfectly  normal  appearance. 

5.  The  vesicula  seminalis  on  the  affected  side  was  healthy.  It  con- 
tained a  small  amount  of  fluid,  with  pus-globules  and  epithelial  cells,  but 
no  si)ermatozoa.  Spermatozoa  were  found  in  the  vesicula  seminalis  on  the 
opposite  side. 

M.  Gaussail  (^Arch.  gen.  de  med.,  1831,  torn,  xxvii,  p.  188)' has  also 
reported  two  cases  of  post-mortem  examination  of  swelled  testicle,  in 
which,  however,  the  examination  was  made  with  less  care  than  in  the  case 
just  quoted. 

Mr.  Curling  (op.  cit.,  p.  249)  says  that  he  has  twice  had  the  oppor- 
tunity of  making  a  post-mortem  examination  of  swelled  testicle,  but  gives 
no  account  of  the  appearances  presented.  ]\Ir.  Brodie'  examined  the 
body  of  a  gentleman  who  had  had  gonorrhoea!  epididymitis  twenty  years 
before,  and  found  the  testicle  smaller  than  natural  and  "one-third  of  the 
tubuli  testis  converted  into  a  white  substance,  having  the  consistence,  but 
not  the  fibrous  structure,  of  ligament." 

With  regard  to  the  changes  which  take  place  in  the  tunica  vaginalis,  we 
have  ourselves  had  some  opportunities  for  observation.  In  one  patient 
under  our  care  the  nodules  of  lymph,  perceptible  on  external  examination, 
were  so  marked  as  to  simulate  the  nodules  of  cancer.     This  case  led  us  to 

'  Clinical  Lecture  on  Diseases  of  the  Testis  :  Lond.  M.  Gaz.,  vol.  xiii,  p.  219, 
1834. 


TREATMENT.  145 

seek  for  subjects  in  the  dead  house,  whose  previous  history  known  to  us  or 
whose  remaining  induration  of  the  epididymis  showed  that  they  had  had 
epididymitis.  The  number  of  bodies  thus  examined  was  twenty.  In 
some  we  found  nodules  of  lymph  on  the  testicular  surface  of  the  tunica 
vao^inalis;  in  others,  on  the  outer  reflection  of  the  same,  and  there  were 
also  in  many  cases  false  membranes  stretching  from  one  reflection  to  the 
other. 

Tlie  first  case  which  I  have  quoted  as  occurring  in  the  service  of  M. 
Yelpeau,  is,  I  believe,  the  only  one  on  record,  in  which  the  examination 
has  been  made  with  all  the  light  which  modern  science  affords,  and  I 
would  especially  call  attention  to  the  fact  that  the  fibrinous  deposit  was 
found  to  be  situated  within  the  vessel  of  the  epididymis  and  not  between 
the  convolutions.  This  fact  is  in  opposition  to  the  statement  of  Mr. 
Curling;  but  it  can  hardly  be  called  in  question  in  the  case  here  reported, 
and  it  strongly  favors  the  opinion  of  M.  Gosselin  that  the  communication 
between  the  testis  and  the  penis  is  almost  invariably  obstructed  during  an 
acute  attack  of  epididymitis,  and  also  during  the  continuance  of  the  indu- 
ration which  is  often  left  behind.  I  would  not  be  understood  as  assertin<»', 
however,  that  the  exudation  is  always  confined  to  the  interior  of  the 
vessel ;  it  may  also  involve  the  areolar  tissue  connecting  the  convolutions, 
but  its  deposit  in  the  former  situation  appears  to  be  the  more  persistent, 
and  the  more  important  so  far  as  the  procreative  powers  of  the  patient  are 
concerned. 

The  pathological  changes  produced  by  epididymitis  can  be  studied  to 
advantage  only  in  recent  cases.  In  the  masses  of  induration  which  have 
existed  for  months  or  years,  the  anatomical  elements  are  so  confounded 
that  it  is  impossible  to  distinguish  them. 

Treatment The  remedies  proposed  for  the  relief  of  gonorrhocal  epi- 
didymitis are  legion  in  number,  too  numerous,  indeed,  even  to  be  recorded 
in  full  in  these  pages.  Some  idea  of  their  diversity  may  be  obtained  by 
consulting  the  columns  of  the  Lancet  for  187G,  when  they  were  called  out 
by  a  discussion  upon  the  value  of  puncture  of  the  testicle  for  this  affection. 
It  may  be  said,  in  general,  that  the  means  now  adopted  are  much  less 
severe  and  heroic  than  a  few  years  ago,  and,  we  have  reason  to  believe,  are 
attended  with  better  results.  I  propose,  first,  to  give  briefly  my  own  jdan 
of  treatment,  and  then  enumerate  a  few  of  the  others  which  have  been  re- 
commended. 

Upon  the  slightest  indication  of  an  attack  of  swelled  testicle,  absolute 
rest  in  the  recumbent  posture  should  be  enjoined.  The  bed  is  the  only 
place  for  the  patient,  since  lying  dressed  upon  the  lounge  will  not  remove 
the  constriction  exercised  by  the  clothes,  nor  permit  of  appropriate  local 
applications.  The  scrotal  organs  must  also  be  well  supported,  and  this  is 
better  done  by  a  handkerchief  sling,  or  by  a  broad  strip  of  adhesive  plaster 
passed  l.nder  the  scrotum  and  made  to  adhere  to  the  thighs,  than  by  a 
suspensory  bandage  as  found  in  the  sliops.  It  is  well  to  unload  the  bowels 
by  a  free  cathartic,  as  thret!  couiiiound  cathartic  pills  or  a  bottle  of  citrate 
of  magnesia.  The  nauseants  and  emetics  formerly  employed  are  now 
10 


146  SWELLED    TESTICLE. 

generally  abandoned,  except  perhaps  Avith  plethoric  subjects,  or  in  cases  of 
general  feblrile  disturbance  ;  and  even  then  the  exhibition  of  aconite  may 
well  be  substituted.  An  opiate  may  be  required  at  night  to  secure  sleep. 
The  diet  should,  of  course,  be  restricted.  Meanwhile  the  patient  has 
enougli  to  attend  to  without  bothering  with  the  antiblennorrhagics  and  in- 
jections which  he  may  have  been  using  for  the  cure  of  his  uretlu'itis. 

As  to  local  applications,  relief  will  often  be  experienced  by  keeping  the 
part  covered  with  a  single  thickness  of  linen  constantly  wet  with  a  solution 
of  the  muriate  of  ammonia,  half  an  ounce  to  a  pint  of  water.  Better  still, 
especially  at  night,  is  to  smear  the  scrotum  freely  with  the  following  mix- 
ture : 

I^.  Ext.  Bellacloniife,    gij 81 

Glycerinas,  ^ss 19 

Aquje,  §j 30] 

M. 

or  with  this  ; 

I^.  Piilv.  Opii,  gij 81 

Gljcerinie,  §j 38; 

M. 

In  either  case,  cover  it  with  a  piece  of  lint  moistened  in  the  same,  and 
envelop  the  whole  in  oil-silk  or  India-rubber  tissue. 

I  have  also  used  with  very  good  effect,  in  some  instances,  a  simple  pro- 
cedure recommended  by  Dr.  Edwin  Lloyd,  of  AVorksop,  Notts  County, 
England.  The  testicle  is  first  immersed  in  water  as  hot  as  cai\  be  borne, 
and  kept  in  it  from  ten  to  fifteen  minutes,  immediately  to  be  followed  by  a 
stream  of  cold  water  poured  over  it  from  a  height  for  five  minutes.  This 
should  be  repeated  two  or  three  times  a  day. 

Under  these  measures  the  epididymitis  may  subside,  but,  probably  in  the 
majority  of  cases,  the  tunica  vaginalis  becomes  involved,  and  more  or  IJfes 
fluid  may  be  detected  in  this  sac.  And  here,  in  our  experience,  comes  in 
the  golden  opportunity  of  giving  almost  instantaneous  relief,  and  cutting 
off  the  further  progress  of  the  disease.  The  means  we  refer  to  consists  in 
the  multiple  punctures  of  the  scrotum  so  highly  recommended  by  Velpeau. 
In  performing  this  slight  operation,  the  tumor  is  rendered  tense  by  grasping 
it  posteriorly  with  the  left  hand,  as  in  making  tlie  puncture  for  hydrocele. 
"With  the  right  liand  the  surgeon,  holding  the  blade  of  a  common  lancet 
between  his  thumb  and  forefinger,  at  the  distance  of  about  one-half  an  inch 
from  its  point,  makes  from  four  to  six  rapid  plunges  into  the  tense  surface 
of  the  scrotum,  still  retaining  his  hold  with  the  left  hand  so  as  to  preserve 
the  parallelism  of  the  incisions  in  the  skin  and  serous  membrane.  If  there 
be  much  fluid  in  the  sac,  it  will  spirt  out  to  some  distance  ;  in  other  in- 
stances, only  a  few  drops  of  serum,  mixed  with  a  little  blood,  escape.  In 
either  case,  the  relief  to  the  sufferings  of  the  patient  is  most  marked,  and 
the  further  progress  of  the  disease  is  at  once  arrested.  The  pain  produced 
by  this  operation  is  so  slight  as  not  to  rerjnire  an  anaesthetic  ;  but  if  the 
patient  be  timid,  I  usually  give  him  a  few  whiffs  of  ether,  or  let  him  inhale 
the  nitrous  oxide  gas,  which  is  now  i)Ut  up  in  a  condensed  form  in  small 


TREATMENT.  147 

cylinders,  and  is  kept  on  hand  by  most  sui'geons  for  this  and  like  minor 
operations.  So  great  is  my  confidence  in  the  effect  of  these  incisions,  that 
I  do  not  hesitate  to  tell  a  patient  that  if  he  will  submit  to  them  he  can  be 
on  his  feet  again  in  two  or  three  days,  I  have  never  seen  the  slightest  ill 
effect  from  them,  although  Montanier^  reports  a  case  in  which  a  simple  in- 
cision into  the  tunica  vaginalis  was  followed  by  excessive  hemorrhage  very 
difficult  to  control,  and  which  even  endangered  life.  Probably  some  scrotal 
artery  of  considerable  size  was  wounded,  but  this  must  be  a  very  rare 
occurrence. 

We  proceed  now  to  mention  other  modes  of  treatment  recommended. 

Sedatives — These  enter,  to  a  greater  or  less  extent,  into  many  of  the 
plans  of  treatment  proposed,  but  they  constitute  the  basis  of  all  treatment 
as  recommended  by  that  accurate  observer,  Mr.  J.  L.  Milton,  and  some 
others.  Mr.  Milton^  says  : — "  The  surgeon's  first  object  is  to  arrest  the 
j)ain  ;  with  this  the  inflammation  stops."^  For  this  purpose  he  prefers 
morphia  in  doses  of  a  quarter  to  half  a  grain  two  or  three  times  a  day,  and 
in  very  severe  cases  gives  three-quarters  of  a  grain  once  or  twice  in  suc- 
cession. In  the  way  of  external  applications,  Mr.  Milton  recommends  the 
following  lotion  : 

B;,     Liq,  Amnion.  Acetatis,.  §  j 30 

Spir.  ^Etheris,  §  iss 45 

Mist.  Camphor.,  §  iiiss 110 

M,  et  sig.  To  be  apjdied  by  means  of  a  single  fold  of  linen,  which  is  to  be  kept 
continuously  wet  with  the  fluid. 

Tliis  is  essentially  the  same  method  as  proposed  by  Mr.  J.  Rouse  ("  Treat- 
ment of  Acute  Orchitis,"  St.  George's  Hosp.  Rep.  Lond.,  vol.  iv,  18G9), 
who  gives  a  purgative  draught  at  the  outset ;  then  follows  with  a  grain  of 
opium  morning  and  night,  and  keeps  the  testicle  enveloped  in  a  hot  fomen- 
tation of  Goulard  and  laudanum..  After  subsidence  of  the  acute  symptoms, 
lie  administers  ''  twenty  drops  of  the  acid  tincture  of  steel"  three  times  a 
day. 

I  have  never  myself  tried  the  effects  of  opiates  alone. 

The  application  of  the  oleate  of  mercury  with  morphia  is  suggested  by 
Prof.  Marshall,  in  the  Lancet  of  May  25,  1872. 

Dr.  Ed.  Warren,  late  chief  surgeon  of  the  Egyptian  army,  injects  be- 
neath the  tunica  vaginalis,  by  means  of  a  hypodermic  syringe,  from  one- 
sixth  to  one-quarter  of  a  grain  of  morphia ;  then  straps  the  testicle  firmly 
with  adhesive  plaster,  and  administers  internally  twenty  grains  of  the 
bromide  of  potassium,  with  fifteen  drops  of  the  tincture  of  gelsemium 
.sempervirens  and  a  drachm  of  the  fluid  extract  of  ergot,  in  half  an  ounce 
of  cinnamon  water,  every  third  hour.  Tlie  injection  of  morphia  is  to  be 
re[)eatcd  at  intervals  of  eight  hours,  if  necessary,  until  a  grain  has  been 
administered.     Relief  is  promised  in  twenty-four  hours  ;  if  it  fail  to  occur, 

'  Uaz.  d.  h6p.,  Par.,  1858,  p.  106. 

2  Pathology  and  Treatment  of  Gonorrhoea,  fourth  edition,  p.  221. 

'  The  italics  are  in  the  original. 


148  SAVELLED    TESTICLE. 

discontinue  the  injections  and  apply  a  narrow  blister  on  either  thigh,  di- 
rectly over  the  femoral  vessels.     (Lancet,  Lond.) 

PnlsatiUa Drs.  Pitfard  and  Fox,  of  New  York,  have  confidence  in  this 

drug,  mnch  used  by  the  homoeopaths  in  the  treatment  of  epididymitis. 
On  inquiry,  I  learn  that  they  give  one-tenth  of  a  drop  of  the  "  mother 
tincture"  every  one  or  two  hours,  and  they  state  that  the  pain  is  speedily 
removed.^  I  have  used  it  myself  in  this  manner  in  a  number  of  cases  with 
very  good  effect,  though  sometimes  it  fails. 

Blood-letting.- — Venesection  in  epididymitis  is,  of  course,  a  thing  of  the 
past.  The  application  of  leeches  to  the  scrotum  has  also  been  well  nigh 
abandoned.  They  may  be  called  for,  however,  when  the  inflammation 
wholly  or  chiefly  involves  the  cord,  and  should  then  be  placed  directly 
over  the  external  abdominal  ring. 

Ice The  application  of  ice  has  been  recommended  by  several  authorities,  ■, 

and  especially  by  M.  Diday;^  but,  according  to  this  author,  in  order  to  be 
successful,  it  must  be  done  with  true  French  precision.  The  following  are 
his  directions:  Two  hogs'  bladders  are  to  be  soaked  for  a  few  minutes,  in 
order  to  soften  them  and  make  them  pliant.  Introduce  into  each,  through 
their  openings,  enlarged  by  a  stroke  of  the  scissors,  four  or  five  pieces  of 
ice  as  large  as  a  goose's  egg.  Before  tying  the  necks  of  the  bladders, 
thoroughly  expel  the  air  from  them,  so  that  they  will  the  better  adapt 
themselves  to  the  surfaces  to  which  they  are  to  be  applied. 

An  excellent  substitute  for  the  hog's  bladder  is  a  bag  of  thin  India- 
rubber,  made  expi'essly  for  this  purpose  and  sold  by  surgical  instrument 
makers. 

The  scrotum  should,  of  course,  be  elevated  by  a  sling  bandage  or  other- 
wise. Beneath  it  is  to  be  })laced  one  of  these  bladders  filled  with  ice,  at 
the  same  time  protecting  the  thighs  and  perinieum  from  the  "impression 
of  cold"  by  the  interposition  of  napkins.  The  second  bladder  naturu'lly 
goes  on  top,  and  is  to  be  extended  as  far  as  the  inguinal  ring. 

To  enter  farther  into  the  details  given  by  M.  Diday  seems  unnecessary, 
since  they  are  such  as  will  suggest  themselves  to  any  one  with  common 
sense,  unless  it  is  important  to  mention  that  "the  ice  should  be  renewed 
when  melted!" 

According  to  M.  Diday,  the  ice  should  remain  on  constantly,  night  and 
day,  for  at  least  eighteen  hours,  but  in  the  majority  of  cases  the  applica- 
tion for  forty-eight  consecutive  hours  is  required.  After  its  removal  we 
are  to  taper  off  with  the  a^jplication  of  cold,  wet  cloths,  lest  the  return  to 
the  natural  heat  of  these  parts  should  cause  too  great  a  shock !  This 
method,  it  is  state<l,  will  supersede  all  others,  even  in  the  most  desperate 
cases  of  swelled  testicle. 

Judging  from  our  ])ersonal    experience,   or    rather  from    our  personal 

1  See  Med.  Rec.  N.  Y.  of  .January  12,  1878,  p.  39.  Also,  same  Journal  for 
Mardi  IG,  1878.  Still  more  recently  Dr.  F.  R.  Sturgis  has  written  iu  favor  of  this 
drug  (The  Med.  and  Surg.  Brief,  July,  1878). 

'^  Ann.  de  derm,  et  syi^h.,  Par.,  1869. 


STRAPPING    THE    TESTICLE.  149 

observation,  the  use  of  cold  applications,  and  especially  of  ice,  in  the 
manner  recommended  by  our  highly  respected  friend,  M.  Diday,  will  be 
found  to  be  of  value  in  some  cases  of  gonorrhoeal  epididymitis,  especially 
at  the  outset  of  the  attack;  but  they  will  prove,  in  the  majority  of  instances, 
insufficient.  One  rule  as  to  their  continuance  is  enough:  if  they  do  not 
afford  relief  within  two  hours,  leave  them  off  and  seek  other  means. 

Poultices If  cold  fails,  then  heat  may  be  tried  in  the  form  of  hot 

poultices — an  old-fashioned  mode  of  treatment,  to  be  sure,  but  one  which 
is  doubtless  of  service  in  some  cases  when  the  patient  is  unwilling  to 
submit  to  puncture  of  the  tunica  vaginalis.  In  these  poultices,  tobacco 
found  a  legitimate  use.  An  ounce  or  so  of  "fine  cut"  was  to  be  mixed  in 
half  a  pint  of  hot  water,  which  was  brought  to  the  boiling  point,  while 
stirring  the  mixture  and  adding  gradually  ground  flaxseed  or  ground  elm- 
bark,  so  as  to  give  it  the  proper  consistency.  The  poultice  should  be 
large  enough  to  envelop  the  whole  testicle;  its  surface  be  covered  by  a 
layer  of  thin  muslin  vipon  which  laudanum  may  be  sprinkled,  and  a  piece 
of  oil-silk  applied  over  the  outer  surface  to  protect  the  bed-clothes. 
Poultices  of  tansy,  stramonium,  hyoscyamus,  and  belladonna,  have  also 
been  recommended;  while  Besnier  (^Bull.  gen  de  therap ;  Par., yew.  1870) 
advises  that  the  scrotum,  carefully  elevated,  should  be  continuously  en- 
veloped by  compresses  saturated  in  a  concentrated  infusion  of  the  leaves  of 
digitalis,  applied  either  hot  or  cold  as  may  be  pleasant  to  the  patient. 

Sti-appiny  the  testicle This  procedure   is  much  less  used   now   than 

formerly.  It  was  first  suggested  by  Dr.  Fricke,^  of  Hamburg,  and  is 
sometimes  called  by  his  name.  It  is  only  a])plicable  after  the  swelling  has 
been  reduced,  the  [lain  dissipated,  and  when  the  parts  will  bear  gentle 
handling.  When  an  indolent  swelling  remains  and  absorption  is  tardy,  I 
not  unfrequently  resort  to  it.  The  rubber  adhesive  plaster,  or  the  mercu- 
rial plaster  prepared  by  Seabury  and  Johnson,  of  New  York,  is  far  more 
cleanly  tiian  the  ordinary  adhesive  plaster;  or,  when  a  sedative  effect  is  also 
desired,  we  may  employ  a  mixture  of  two  parts  of  adhesive  plaster  with 
one  of  extract  of  belladoinia,  spread  upon  thin  leather. 

Before  applying  the  plaster,  the  hair  should  be  carefully  removed  from 
the  scrotum  witii  a  razor  or  scissors.  The  plaster  is  to  be  cut  into  strips 
about  tiiree-quarters  of  an  inch  in  width.  The  testicle  is  now  to  be  pressed 
down  to  the  lower  portion  of  the  sac,  and  held  there  by  the  thumb  and 
forefinger  of  the  left  hand,  while  a  strip  is  placed  firmly  round  the  affected 
side  of  the  scrotum,  just  below  the  abdominal  ring.  Successive  strips  are 
added,  each  one  overlapping  the  preceding  for  one-third  its  width,  and 
care  being  taken  that  they  all  fit  smoothly,  until  all  but  tiie  bottom  of  the 
testicle  is  enveloped;  the  latter  should  be  covered  with  strips  applied 
longitudinally,  like  the  bottom  of  a  wick(!r  basket,  and  finally  the  whole  is 
to  be  secured  by  a  long  narrow  strip  carried  circularly  several  times 
around   the   tumor.     In  the  course  of  from  twelve    to  twenty-four  hours, 

'  Ztsclir.  f.  (1.  ges.  Med.,  Ilamb.,  183G.  Tr;mshition  in  Brit,  and  Fur.  M.  Kev,, 
Loud.,  18I3G,  vol.  i.  p.  253. 


150 


SWELLED    TESTICLE. 


the  plaster  will  be  found  to  be  loosened  by  the  decrease  of  the  swelling, 
when  it  should  be  removed  and  fresh  strips  applied.  The  compi-ession 
should  be  continued  until  the  testis  has  nearly  returned  to  its  normal  di- 
mensions, and  in  the  meantime  the  parts  still  be  supported  by  a  bandage. 
CuUerier  states  that  strapping  the  testicle  has  been  entirely  abandoned  in 
France. 

Prof.  Thiry,  of  Brussels,  the  most  eminent  syphilographer  of  Belgium, 
has  been  publishing  a  long  series  of  lectures  on  gonorrheal  epididymitis  in 
the  Presse  vied,  helge.,  1876-7,  in  Avhich  he  strongly  advocates  the  well 
nigh  abandoned    strapping.      He    claims    that  it  has  fallen  into  disuse, 

Fig.  39. 


Miliano's  compressive  suspeasorium. 


chiefly  because  it  has  been  reserved  for  the  stage  of  decline  after  the 
inflammatory  symptoms  have  subsided,  while,  in  his  oi)inion,  the  time  for 
its  application  is  the  '■'^periode  de  stade"  i.  e.,  when  tlie  inflammation  has 
fully  reached  its  height.  When  called  to  a  case,  he  first  ascertains  if  the 
general  febrile  disturbance  has  subsided,  and  any  trouble  in  the  digestive 
organs  has  disappeared.     If  not,  he  gives  an  emetic,  "  which  soon  makes 


ANTIMONIAL    FRICTIONS — PUNCTURES.  151 

that  all  right,"  ami  proceeds  at  once  to  strapping.  He,  however,  rejects 
all  plasters  for  this  purpose,  and  uses  only  narrow  strips  of  muslin  which 
are  made  to  envelop  the  testicle  in  six  to  eight  layers.  The  mode  of 
application  is  about  the  same  as  that  in  genei'al  use,  except  that  each  strip 
when  applied  is  finally  to  be  brought  back  to  the  strip  encircling  the  neck 
of  the  scrotum.  The  whole  is  retained  in  place  by  spreading  starch-paste 
on  the  last  two  layers  applied. 

Dr.  G.  Miliano  accomplishes  compression  of  the  inflamed  testicle  by  a 
suspensory  bandage,  that  can  be  gradually  tightened  as  the  testicle  dimin- 
ishes in  size.     The  accompanying  wood-cut  will  explain  itself. 

Antimoninal  frictions — This  method  was  introduced  in  Strasbourg,  by 
M.  Michel,  in  186-3.  It  consists  in  making  minute  punctures  along  the 
cord  from  the  scrotum  to  the  external  abdominal  ring,  and  then  repeatedly 
rubbing  in  an  antimonial  ointment  (pommade  d'  Autenrietli),^  until  pus- 
tules appear,  the  coalescence  of  which,  however,  should  be  avoided,  lest 
ugly  cicatrices  result.  The  pain  is  said  to  cease  in  forty-eight  hours,  and 
a  cure  to  be  effected  toward  the  end  of  thirty  days.  I  think  we  can  beat 
that ! 

Solutions  of  nitrate  of  Silver Fourneux  Jordan^  treats  epididymitis  by 

the  application  to  the  affected  side  of  the  scrotum  of  a  solution  of  nitrate 
of  silver  (Jij  ad  Aqua?  gj)  followed  by  gentle  pressure. 

Dr.  Marc  Girard  applies  to  the  affected  testicle  lint  soaked  in  a  solution 
of  nitrate  of  silver,  one  part  to  one  hundred  of  water.  In  five  cases  treated 
in  this  way,  at  the  military  Hospital  of  Gand.  the  pain  ceased  in  about 
twenty-four  hours,  and  the  average  length  of  treatment  was  six  days.  "  The 
mode  of  action  of  the  remedy  is  unknown  ;  it  is  not  by  revulsion,  since  it 
does  not  cause  any  pain  but  merely  a  pleasant  sensation  of  heat,  and  it  does 
no  more  to  the  skin  than  slightly  discolor  it."  (Arch.  med.  beiges,  Brux., 
aout,  1870.) 

Collodion  and  ether The  application  of  collodion  to  flie  scrotum  as  a 

means  of  compression,  suggested  by  M.  Bonnaf'ont,  was  a  subject  of  dis- 
cussion before  tlie  Academy  of  Medicine  in  Paris,  in  1854,  and  a  trial  was 
made  of  it  by  Ricord  and  others,  who  reported  against  it.  Dr.  Assadorian' 
recommends  the  local  application  of  sulphuric  ether,  a  piece  of  lint  kept 
constantly  wet  with  this  fluid  being  laid  over  the  inflamed  testicle  and  cord, 
and  the  bed-clothes  being  elevated  by  a  hoop,  so  as  to  fjxvor  free  evapo- 
ration. 

Punctures — I  have  already  spoken  of  the  multiple  punctures  proposed 
by  Yelpeau,  and  expressed  my  confidence  in  them  for  the  relief  of  swelled 
testicle,  no  matter  how  small  the  cpiantity  of  fiuid  contained  within  the 
tunica  vaginalis.     This  procedure,  which  is  also  highly  recommended  by 

'   R.     Aiitimonii  et  PotJissii  Tartratis,    .     .    one  part. 

Axiuigisu  b(3nzoatae tliree  parts. 

M. 

2  Brit.  M.  J.,  Lond.,  quot<'(l  in  N.  York  .J.  M.,  Oct.,  1869,  p.  63. 
^  Am.  .J.  Sypli.  and  Derm.,  vol.  i,  p.  216. 


152  SWELLED    TESTICLE. 

CuUerier,  is,  I  believe,  sufficient  for  the  relief  of  :ill  Cixses,  without  resort 
to  any  deeper  incision. 

The  late  M.  Vidal  (de  Cassis)  revived  an  operation  which  is  said  to 
have  originated  with  a  French  surgeon  by  the  name  of  Petit,  who  pub- 
lished a  work  on  venereal  in  1812.  This  operation  is  simply  an  extension 
into  the  substance  of  the  testicle  of  the  incisions  recommended  by  Velpeau. 
Yidal  states  that  he  first  employed  these  incisions  in  swelled  testicle  when 
the  body  of  the  testicle  was  involved,  to  which  form  of  the  disease  he  gives 
the  name  of  parenchymatous  orchitis.  His  design  was,  by  dividing  the 
tunica  albuginea  to  relieve  the  constriction  exercised  by  this  fibrous  tunic 
upon  its  inflamed  contents.  Finding,  as  he  says,  that  the  operation  was 
unattended  by  any  unpleasant  result,  and  that  it  relieved  the  pain  and 
hastened  resolution,  he  extended  it  to  the  more  frequent  cases  in  which 
the  epididymis  is  alone  attacked,  and  found  the  effect  equally  favorable. 
In  his  work  on  venereal,  this  author  states  that  he  has  performed  this 
operation  Avith  impunity  in  four  hundred  cases,  and  claims  for  it  prefer- 
ence to  all  other  modes  of  treatment.  His  directions  as  to  the  manner  of 
performing  it  are  to  incise  the  tunica  albuginea  with  a  bistoury  or  lancet 
passed  through  the  scrotum  and  tunica  vaginalis,  to  the  extent  of  six- 
tenths  of  an  inch  (kh  centimetre  et  demi"),an([  to  penetrate  the  parenchyma 
of  the  testicle  to  the  depth  of  less  than  three-tenths  of  an  inch  (de  molns 
de  moitie).  Only  one  puncture  of  this  kind  is  to  be  made.  In  spite  of 
M.  Vidal's  testimony  in  its  favor,  we  can  hardly  believe  this  operation 
entirely  devoid  of  danger,  especially  since  the  report  of  four  cases  observed 
by  a  single  surgeon,  M.  Demarquay,  in  which  the  substance  of  the  testicle 
gradually  oozed  from  the  incision  in  filaments,  and  in  three  of  which  the 
testicle  was  totally  lost,^  Salleron  gives  two  similar  cases. ^  Diday  also 
reports  two  cases  in  which  atrophy  of  the  testicle  followed  Yidal's  incision.* 
If  resorted  to  at  all,  it  should  probably  be  reserved  for  those  cases  in  which 
it  was  first  used,  viz.,  where  the  body  of  the  testicle  is  extensively  im- 
plicated. 

Mr.  Henry  Smith,*  surgeon  to  King's  College  Hospital,  London,  has 
advocated  the  same  treatment  by  incision  into  the  body  of  the  testicle, 
and  states  that  he  has  met  "'with  results  which  have  astonished  himself 
and  his  numerous  pupils."  Mr.  Smith's  recommendation  has  excited  a 
lively  discussion  in  some  of  tlie  London  medical  journals. 

Numerous  other  topical  remedies  have  been  recommended  in  gonorrhoeal 
epididymitis,  but  many  of  them  are  not  worthy  of  mention.  Inunctions 
of  mercurial  ointment  upon  the  scrotum  may  relieve  the  pain,  but  are  liable 
to  cause  salivation.  They  may  be  used  with  caution  in  those  cases  in 
which  the  acute  symptoms  have  subsided,  leaving  chronic  engorgement  of 
the  epididymis. 

'  Brit,  and  For.  Med.-Chir.  Rev.,  American  edition,  April,  1859,  from  the  Bui. 
gdn.  detlierap.,  Par.,  tome  Iv,  p.  549. 

2  Arch,  gen,  de  med.,  Fev.  1870. 

3  Ann.  de  derm,  et  sypli.,  Par.,  18(39.  *  Lancet,  Lond.,  1864. 


IODOFORM.  153 

The  late  Prof.  W.  Boeck,  of  Christiania,  spoke  highly  of  a  curious  mode 
of  treatment,  viz.,  the  injection  of  a  few  drops  of  a  solution  of  nitrate  of 
silver  into  the  prostatic  urethra,  and  stated  that  the  pain  and  swelling 
were  thus  relieved  in  twenty -four  hours,  provided  they  were  not  de- 
pendent upon  effusion  into  the  tunica  vaginalis.   (Oral  Com.) 

Dr.  L.  D.  Waterman,  of  Indianapolis,  reports^  a  plan  of  treatment  which 
he  states  has  been  eminently  successful  in  his  hands  and  others.  He  ad- 
ministers internally  acetate  of  potassa  with  acetate  of  morphia,  the  latter 
so  graduated  as  to  secure  full,  but  not  excessive,  anodyne  effects.  Locally, 
he  employs  a  liniment  composed  of 

Thict.  lodinii,  Tinct.  Opii, 

Aq.  Ammoiiife,  01.  Olivse.  M. 

The  proportions  of  the  iodine  and  ammonia  are  so  graduated  that,  when 
a  woollen  cloth,  saturated  hourly  Avith  the  liniment,  is  kept  constantly 
applied  to  the  scrotum,  the  effect  will  be  bearable  and  only  cause  half 
blistering  of  the  skin  or  exfoliation,  with  a  stinging  sensation  for  a  short 
time  after  application.  The  pain  is  said  to  cease,  sometimes  in  three  hours, 
always  within  twenty-four,  and  the  effusion  to  be  rapidly  absorbed  without 
tapping. 

Iodoform Dr.  Julian  Alvar«z,^  of  Palma,  Majorca,  i-eports  four  cases 

of  epididymitis,  successfully  treated  by  the  application  of  iodoform  oint- 
ment. He  claims  that  this  agent  calms  the  pain  in  the  course  of  one  or 
two  hours  ;  that  it  exercises  a  very  marked  resolvent  action,  and  materially 
shortens  the  duration  of  the  disease.  He  uses,  according  to  the  intensity 
of  the  inflammation,  an  ointment  containing  one  to  two  grammes  of  iodo- 
form to  the  ounce  of  lard. 

In  a  similar  manner,  iodoform  has  for  several  years  been  used  with  vexy 
satisfactory  results,  at  the  Charity  Hospital,  Blackwell's  Island,  where  it 
was  first  proposed  by  Dr.  R.  W.  Taylor.  One  drachm  of  iodoform  mixed 
with  one  ounce  of  glycerine  is  painted  upon  the  testicle,  which  is  to  be 
enveloped  in  lint  and  covered  with  oil-silk  or  India-rubber  tissue. 

The  induration  of  the  epididymis,  which  is  usually  left  behind  after  the 
subsidence  of  the  acute  symptoms  of  an  attack  of  swelled  testicle,  will 
sometimes  disappear  spontaneously.  If,  however,  it  is  inclined  to  persist, 
the  earlier  it  is  attacked  the  better,  for  the  chances  of  success  are  certainly 
superior  while  the  plastic  material  is  not  yet  fully  organized.  If  the  in- 
durated epididymis  is  still  abnormally  sensitive  to  pressure,  the  application 
of  a  few  leeches  over  the  cord,  repeated  several  times  at  intervals  of  a 
few  days,  will  be  found  of  service.  A  small  quantity  of  mercurial  oint- 
ment should  be  rubbed  into  the  scrotum  morning  and  night,  and  the 
genital  organs  should  be  well  supported  by  a  suspensory  bandage. 

Another  local  application  worthy  of  trial  is  the  iodide  of  lead  ointment, 
or  an  ointment  of  iodoform,   one  scruple   to   half  an  ounce  of  lard,  the 

'  Practitioner,  Loud.,  Novoiiibor,  187'),  p.  334. 
2  Iiiilcpend.  iiied.,  Barct'l.,  June  1,  1877. 


154  SWELLED    TESTICLE. 

Strength  of  which  may  be  increased  :  the  latter  especially  has  proved  of 
service  in  our  hands.  The  application  should  be  made  directly  over  the 
indurated  mass.  Much  is  to  be  exjjected  also  from  the  internal  adminis- 
tration of  iodide  of  potassium,  which  is  so  powerful  an  agent  in  resolving 
inflammatory  products  generally. 

It  is  impossible  to  say  how  old  an  induration  of  the  epididymis  can  be 
treated  with  hopes  of  success.  M.  Gosselin's  cases  show  that  it  may  dis- 
appear after  existing  for  several  months,  and  it  is  not  improbable  that  a 
cure  may  be  effected  after  a  much  longer  period.  Where  the  epididymis 
on  both  sides  is  affected,  the  attempt  should  certainly  be  made,  especially 
if  the  patient  is  young  and  intends  to  marry.  It  is  a  serious  question 
whether  the  surgeon  should  inform  him  of  the  impotency  which  his  disease 
may  entail,  since  the  effect  upon  his  mind  might  possibly  be  most  disas- 
trous. 


HYDROCELE.  155 


CHAPTER  XI. 

HYDROCELE. 

By  the  term  hydrocele  we  understand  a  serous  effusion  into  the  cavity 
of  the  tunica  vaginalis,  producing  more  or  less  distention  of  the  scrotal 
sac.  Upon  examination  we  find  a  pear-shaped  tumor,  having  its  base  at 
the  bottom  of  the  scrotum,  and  its  apex  directed  towards  the  external 
abdominal  ring.  The  size  of  the  tumor  of  course  varies  with  the  amount 
of  effusion ;  it  is  firm  and  elastic,  and  on  its  anterior  surface  fluctuation 
may  be  made  out,  Avhile  posteriorly  we  encounter  the  hard,  firm  body  of 
the  testicle,  which  has  the  characteristic  sensation  upon  pressure.  The 
walls  of  the  scrotum  are  tense,  and  the  superficial  veins  are  distended. 
There  is  absolute  dulness  on  percussion  of  the  tumor.  The  crucial  test  in 
making  a  diagnosis  is  the  familiar  "light  test."  Looking  at  the  tumor 
through  a  cylinder  of  paper,  or  shading  the  eye  with  the  hands,  the  light 
being  held  on  the  opposite  side  of  the  scrotum,  distinct  translucency 
may  be  observed  anteriorly,  while  posteriorly  the  opaque  body  of  the 
testis  is  detected.  In  chronic  cases  the  "  light  test"  may  be  inapplicable 
on  account  of  the  thickening  of  the  tunica  vaginalis.  Owing  to  the  diffu- 
sion of  the  rays  of  light  in  the  fluid  the  testicle  always  seems  much  smaller 
than  we  expect  to  find  it.  In  somewhat  rare  cases  we  find  the  testis  situ- 
ated anteriorly  and  at  the  upper  part  of  the  tumor,  the  tunica  vaginalis 
being  placed  posteriorly.  If  any  doubt  remains  as  to  the  character  of  the 
tumor,  puncture  with  a  hypodermic  needle  may  be  resorted  to. 

The  fluid  of  hydrocele  usually  has  a  pale  straw  color,  and  is  highly 
albuminous.  It  lias  been  found  of  a  dark  brown,  of  a  greenish  color,  and 
even  black.  It  sometimes  contains  a  small  quantity  of  ciiolesterine,  and  in 
a  few  instances  spermatozoa  have  been  found  in  it.  After  exposure  to  the 
air  the  fluid  sometimes  sejiarates  into  distinct  layers,  and  it  has  been  found 
to  coagulate  on  the  addition  of  blood. 

In  recent  cases  very  little  change  is  found  in  the  structure  of  the  tunica 
vaginalis,  although  if  the  effusion  takes  place  rapidly,  or  in  large  quantity, 
the  tunica  may  be  much  thinned.  In  old  cases,  however,  the  tunica  be- 
comes very  much  thickened,  and  may  interfere  with  the  translucency  of 
the  tumor,  and  in  (jtiite  rare  cases  it  undergoes  calcareous  degeneration. 
The  testis  is  generally  unaffected,  but  in  chronic  cases  may  become  atro- 
phied. Cjsts  have  been  found  projecting  from  its  surface  into  the  cavity 
of  the  tunica  vaginalis.  The  hydrocele  is  sometimes  divided  into  com- 
partments by  adhesions  between  the  surfaces  of  the  tunica. 

The  causes  of  hydrocele  are  various.  It  sometimes  occurs  as  a  compli- 
cation of  general  dropsy,  especially  in  broken  down  subjects.    It  frequently 


156  nYDROCELE. 

accompanies  varicocele,  probably  as  a  result  of  tlie  inipedinient  to  the  cir- 
culation. The  etiology  of  hydrocele  has  been  carefully  studied  by  Panas 
and  Vetault,^  who  think  it  is  generally  due  to  infiammation  of  the  epidi- 
d}  mis.  In  the  latter,  the  efferent  vessels  of  the  testis  are  often  compressed 
by  newly -formed  fibrous  tissue  to  such  a  degree  as  to  produce  effusion  into 
the  tunica  vaginalis.  In  many  cases  of  acute  and  of  chronic  orchitis  effu- 
sion takes  place,  which  is  very  often  absorbed,  but  frequently  remains. 
It  is  stated  by  some  authors  that  hydrocele  is  frequent  in  very  warm  cli- 
mates, perhaps  owing  to  the  relaxation  of  the  scrotum. 

The  diagnosis  of  hydrocele  is  generally  quite  easy.  Its  slow  develop- 
ment, its  beginning  at  the  bottom  of  the  scrotum,  its  pyriform  shape,  and 
its  painless  character  are  presumptive  symptoms,  while  all  doubt  may  be 
removed  by  the  use  of  the  light-test.  Some  cases  of  incarcerated  hernia 
resemble  it  somewhat,  but  the  following  table  of  diagnostic  points,  taken 
from  Van  Buren  and  Keyes's  valuable  work,  presents  clearly  the  distin- 
guishino;  features  of  the  two  affections. 

Hydrocele.  Incakcerated  Hernia. 

1.  Largest  below.  1.  Largest  above. 

2.  Commences  gradually.  2.  Comes  on  suddenly. 

3.  Commences  at  the  bottom  of  the  3.  Commences  at  the  external  ring  and 
scrotum  and  grows  up.  grows  down. 

4.  Is  tense  and  fluctuating.  4.  Is  usually  doughy. 

5.  Cord  can  be  made  out  (normal)  5.  Cord  cannot  be  distinguished,  or  is 
above  tumor.  felt  as  a  distinct  tumor. 

6.  Testicle  cannot  be  found.  (5.  Testicle  can  usually  be  separated 

fi'om  tumor  posteriorly. 

7.  Dulness  on  percussion.  7.  Resonance   on   percussion    (unless 

hernia  be  omental). 

8.  Tumor  heavy,  but  movable.  8.  Tumor  unwieldy.  ■• 

9.  Reduction  impossible.  9.  Reduction  impossible. 

10.  Size  usually  constant.  10.  Size  usually  varies  at  short    in- 

tervals. 

The  translucency  of  hydrocele  always  establishes  the  diagnosis  between 
it  and  solid  tumors  of  the  testis,  resulting  from  syphilis,  cancer,  or  tuber- 
cular deposits. 

TuEATMENT. — The  treatment  of  hydrocele  may  be  palliative  or  radical; 
by  the  former  we  merely  remove  the  fluid,  by  tiie  latter  we  hope  to  prevent 
its  reformation.  Although  it  has  been  claimed  that  absorption  of  tlie  fluid 
may  be  secured  by  means  of  electrolysis,  experience  has  shown  this  method 
to  be  uncertain  as  well  as  impracticable.  Acupuncture  is  open  to  the 
serious  objection  that  it  often  fails  to  com[)letely  evacuate  the  fluid:  more- 
over it  does  not  prevent  rela])se,  and  it  is  often  followed  by  excessive 
inflammation.  This  metliod  is  used  by  some  in  the  hydrocele  of  young 
children,  which  may  often  be  cured  merely  by  external  stimulation  with 
tincture  of  iodine. 

'  Considerations  fetiologiques  sur  rhydroclde  des  adultes.     Paris,  1872. 


CONGENITAL  HYDROCELE.  157 

Tapping  of  the  tunica  vaginalis  with  a  fine  trocar  is  the  best  way  to  re- 
move the  fluid.  The  instrument  should  be  inserted  slightly  upwards  as 
well  as  inwards,  care  being  taken  to  avoid  large  veins  of  the  scrotum.  The 
scrotum  should  be  held  tense  with  the  left  hand  when  •  the  instrument  is 
plunged  into  the  tumor,  and  the  canula  must  fit  tlie  trocar  perfectly,  else 
it  may  push  the  tunica  vaginalis  before  it,  rather  than  pierce  it.  The  ope- 
ration may  end  after  withdrawal  of  the  fluid;  but  if  we  aim  at  a  radical 
cure,  we  inject,  with  a  syringe  closely  fitting  the  canula,  about  two  drachms 
of  tincture  of  iodine,  which  should  be  brought  into  contact  with  all  parts 
of  the  tunica  by  manipulating  the  scrotum.  The  injection  may  then  be 
allowed  to  run  out,  although  usually  only  a  few  drops  escape.  The  after- 
treatment  consists  of  rest  and  the  application  of  a  cooling  lotion  to  relieve 
excessive  pain.  The  reaction  is  sometimes  very  sliglit,  while  in  other 
cases  it  is  very  marked.  In  the  majority  of  cases  this  operation  produces 
a  radical  cure,  but  it  certainly  fails  in  some  instances. 

Of  late  years  the  operation  proposed  by  Volkmann  has  found  favor  with 
most  surgeons.  It  should  be  performed  with  great  care  and  always  by  the 
antiseptic  metliod.  It  consists  in  opening  the  tunica  vaginalis  by  an  in- 
cision throughout  its  entire  length.  The  incised  edge  of  the  scrotum  is 
then  stitched  to  the  corresponding  edge  of  the  tunica  and  the  wound  is 
left  open  exposing  the  cavity.  This  seldom  fails  to  give  a  radical 
cure.  The  operation  of  passing  threads  of  silk  through  the  scrotum  is  not 
now  looked  upon  with  favor,  since  it  is  frequently  followed  by  severe  in- 
flammation, and  sometimes  by  sloughing  of  the  scrotum,  while  it  is  not 
always  successful.  In  old  men,  particularly  if  they  are  in  poor  health,  a 
few  days  of  rest  should  always  be  enjoined  after  tap[)ing  a  hydrocele.  In 
case  the  tumor  is  very  large  it  may  be  well  to  draw  off  only  a  portion  of 
the  fluid  at  the  first  operation,  which  may  be  repeated  in  a  few  days. 

Congenital  Hydrocele. 

This  affection  is  due  to  incomplete  obliteration  of  the  canal  which  forms 
a  communication  between  the  tunica  vaginalis  and  the  peritoneal  cavity. 

The  sha[)e  of  the  tumor  differs  from  that  of  a  hydrocele  in  the  adult, 
being  oblong  rather  than  pyriform,  and  extending  up  into  the  external 
abdominal  ring.  The  fluid  may  by  pi'cssure  be  displaced  into  the  ab- 
dominal cavity,  where  it  was  probably  originally  secreted  ;  this  may  be 
accomplished  with  more  or  less  ease  according  as  the  opening  from  the 
tunica  vaginalis  is  large  or  small.  In  a  case  mentioned  by  Curling  this 
could  not  be  fully  accomplished  after  manipulating  tlie  tumor  for  fifty  min- 
utes. Tiie  testicle  can  be  readily  felt  after  the  hydrocele  has  been  thus 
emptied.  In  this  form  of  hydrocele  there  is  marked  impulse  on  coughing. 
The  tumor  is  translucent,  and  dull  on  percussion,  unless,  as  is  sometimes 
the  case,  a  hernia  coexists. 

Tiie  treatment  of  this  affection  consists  in  the  application  of  a  nicely 
fitting  truss  over  the  neck  of  the  sac,  which  soon  becomes  obliterated. 
Usually  the  fluid  is  gradually  absorbed  at  the  same  time,  but  the  process 


158  HYDROCELE. 

may  be  hastened  by  the  local  use  of  tincture  of  iodine.  The  injection  of 
iodine  into  the  cavity  of  the  hydrocele  has  been  practised  by  some  sur- 
geons without  bad  results,  care  having  been  taken  to  compress  the  neck 
of  the  sac.  In  other  cases,  however,  fatal  peritonitis  has  followed  this 
operation:  it  should  therefore  not  be  employed  until  communication  with 
the  abdominal  cavity  is  entirely  cut  oif. 

Encysted  Hydrocele  of  the  Testis. 

There  are  two  varieties  of  this  kind  of  hydrocele,  one  arising  from  the 
epididymis  and  the  other  from  the  body  of  the  testicle.  Either  variety 
may  be  complicated  by  hydrocele  of  the  tunica  vaginalis.  According  to 
Gosselin,  Luschka,  and  Curling,  these  cysts  are  of  two  kinds,  subserous 
and  parenchymatous,  or  small  and  large. 

The  covering  or  walls  of  the  subserous  cysts,  which  are  superficial,  are 
composed  simply  of  stretched  serous  membrane,  while  the  walls  of  the 
parenchymatous,  which  are  developed  in  the  connective  tissue,  are  dense 
and  firm.  The  subserous  cysts  are  usually  multiple,  and  are  found  above 
and  around  the  head  of  the  epididymis  ;  they  are  generally  about  the  size 
of  a  pea.  They  contain  a  clear,  pellucid  fluid,  which  is  sometimes  of  a 
milky  hue  ;  spermatozoa  are  never  found  in  the  fluid.  These  cysts  some- 
times become  fused  together,  and  form  a  single  large  one,  having  a  pedun- 
culated base ;  they  never  have  any  connection  with  the  eflferent  tubes  of 
the  testis  and  rarely  cause  any  uneasiness.  Occasionally,  when  very  old, 
these  small  cysts  have  such  thick  walls  as  to  be  mistaken  for  solid 
tumors. 

The  large  cysts,  according  to  Curling,  are  usually  found  "  below  the 
head  of  the  epididymis,  close  to  the  anterior  extremity  of  its  lower  border. 
They  are  formed  in  the  connective  tissue  beneath  the  investing  membrane 
of  the  epididymis  and  in  close  contact  with  the  efferent  tubes."  These 
have  received  the  name  of  encysted  hydrocele  of  the  epididymis.  The 
epididymis  is  flattened  and  displaced  laterally,  wliile  the  testis  is  found 
below,  in  front  of,  or  at  the  side  of  the  cyst,  very  rarely  behind  it.  Mr. 
Curling  gives  an  illustration  of  a  striking  case  of  this  form  of  cyst,  which 
was  distinctly  sacculated.  The  contained  fluid  is  sliglitly  albuminous, 
colorless  and  sometimes  contains  an  abundance  of  molecules.  Curling 
states  that  this  form  of  cyst  is  liable  to  inflammation,  when  the  fluid  be- 
comes albuminous  and  of  a  straw  color;  the  cysts  may  even  become  lined 
Avith  a  false  membrane.  Spermatozoa  are  not  infrequently  found  in  the 
fluid.  Regarding  the  doubtful  origin  of  these  bodies,  Mr.  Paget  says  "  that 
certain  cysts  seated  near  the  organ,  which  naturally  secretes  the  material 
for  semen,  may  possess  the  power  of  secreting  a  similar  fluid."  Curling 
however,  does  not  accept  this  view.  In  his  o})inion,  the  thin  walls  of  the 
sac  being  in  close  proximity  with  the  ett'erent  tubes,  which  are  likewise 
of  slight  texture,  a  rupture  occurs  allowing  the  spermatozoa  to  pass  into 
the  cyst.  Being  merely  an  accident,  he  thinks  the  term  spermatic  hydro- 
cele is  improperly  applied  to  this  condition. 


HYDROCELE    OF    THE    SPERMATIC    CORD.  159 

Cysts  springing  only  from  the  body  of  tlie  testis  are  quite  rai-e.  They-- 
are  due  to  effusion  between  the  tunica  albuginea  and  the  deeper  layer  of 
the  tunica  vaginalis.  Occasionally  a  cyst  is  seated  partly  upon  the  epidi- 
dymis and  partly  upon  the  testicle.  The  walls  of  a  recent  cyst  are  thin 
and  translucent ;  as  the  cyst  grows  older,  its  walls  become  thick,  dense  and 
fibrous,  sometimes  even  containing  spiculaj  of  bone,  and  becoming  lined 
with  false  membrane.  The  fluid  is  at  first  pellucid,  but  after  a  time  it 
assumes  a  yellow  or  even  a  deep  brown  color. 

Diagnosis Encysted  hydrocele  of  the  epididymis  is  usually  recog- 
nized from  the  position  and  number  of  the  cysts.  In  cases  of  doubt,  espe- 
cially when  the  cysts  are  hard  and  firm,  the  introduction  of  a  hypodermic 
needle  will  determine  whether  they  contain  fluid.  The  difference  in 
shape  between  these  large  cysts  and  hydrocele  of  the  tunica  vaginalis  is  an 
important  point,  while  the  position  of  the  testicle  at  the  bottom  of  the 
tumor  confirms  the  suspicion  of  large  encysted  hydrocele. 

In  some  cases,  however,  on  account  of  abnormalities  in  position,  a  posi- 
tive diagnosis  can  only  be  made  by  drawing  off  some  of  the  fluid,  which  is 
generally  pellucid  or  milky,  ratlier  than  straw  colored.  Translucency  and 
fluctuation  are  additional  points  in  the  diagnosis. 

Trkatment — The  small  encysted  hydrocele  seldom  requires  any  atten- 
tion, unless  it  tends  to  increase  in  size  or  become  painful,  Avhen  the  fluid 
may  be  drawn  off  with  a  hypodermic  needle  or  by  acupuncture.  This 
operation  sometimes  gives  permanent  relief,  but  may  need  to  be  repeated. 
Large  cysts  should  be  tapped  separately,  and  injected.  Sometimes  tlie 
tapping  and  injection  of  a  single  cyst  causes  subsidence  of  all  the  rest. 
Although  the  seton  has  been  used  with  success,  it  sometimes  causes  violent 
inflammation  and  abscess.  Volkmann's  operation  may  be  employed  after 
failure  of  tapping. 

Hydrocele  of  the  Spermatic  Cord. 

There  are  tAvo  varieties  of  liydrocele  of  the  cord,  the  diffused  and  the 
encysted. 

The  diffused  form  is  merely  a  serous  infiltration  into  the  loose  and 
abundant  connective  tissue  of  the  cord.  The  first  clear  description  of  the 
lesion  was  given  by  Pott.  "  In  general,  while  it  is  of  moderate  size,  the 
state  of  it  is  as  follows :  the  scrotal  bag  is  free  from  all  appearance  of  dis- 
ease, except  that  when  the  skin  is  not  congested  it  seems  rather  fuller, 
and  hangs  rather  lower  on  that  side  than  on  the  other ;  and,  if  suspended 
lightly  in  the  palm  of  the  hand,  feels  heavier  ;  the  testicle  with  its  epidi- 
dymis is  to  be  felt  perfectly  distinct  below  this  fulness,  neither  enlarged 
nor  in  any, manner  altered  from  its  natural  state  ;  the  spermatic  process  is 
considerably  larger  than  it  ought  to  be,  and  feels  like  a  varix  or  like  an 
omental  hernia,  according  to  the  difterent  sizes  of  the  tumor ;  it  has  a 
pyramidal  kind  of  form,  broader  at  the  bottom  than  at  the  top  ;  by  gentle 
and  continued  pressure  it  seems  gradually  to  recede  or  go  up,  but  drops 
down  again  immediately  upon  removing  the   pressure,  and   that  as  freely 


160  HYDROCELE. 

in  a  supine  as  in  an  erect  posture.  It  is  attended  Avitli  a  very  small  de- 
gree of  pain  or  uneasiness,  which  uneasiness  is  not  felt  where  the  tume- 
faction is,  but  in  the  loins.  If  the  extravasation  be  confined  to  what  is 
called  the  spermatic  process,  the  opening  in  the  tendon  of  the  abdominal 
muscle  is  not  at  all  dilated,  and  the  process  passing  through  it  may  be 
very  distinctly  felt ;  but  if  the  cellular  membrane,  which  invests  the 
spermatic  vessels  within  the  abdomen,  be  aftected,  the  tendinous  aperture 
is  enlarged,  and  the  increased  size  of  the  distended  membrane  passing 
through  it  produces  to  the  touch  a  sensation  not  very  unlike  that  of  an 
omental  rupture."  Curling  says  that  the  tumor  is  at  first  cylindrical,  and 
becomes  pyramidal  as  it  enlarges.  The  penis,  in  this  affection,  is  never 
retracted,  as  it  is  in  vaginal  hydrocele. 

This  form  of  hydrocele  may  be  mistaken  for  a  hernia.  The  latter  often 
passes  into  the  abdomen  when  the  patient  lies  down,  while  the  former  is 
but  slightly  if  at  all  disi)laced.  The  swelling  of  hydrocele  is  firmer, 
though  doughy,  and  fluctuating  ;  a  hernia,  moreover,  unless  it  be  omen- 
tal, is  resonant  on  percussion.  The  impulse  on  coughing  in  hernia  is 
quite  different  from  the  very  slight  downward  movement  of  the  enlarged 
cord  in  hydrocele.  In  hernia  the  cord  can  always  be  traced  of  normal 
size  from  the  testis  to  the  ring.  Scarpa  calls  attention  to  the  resemblance 
of  this  form  of  hydrocele  to  an  irreducible  epiplocele,  and  to  the  necessity 
of  caution  in  operating. 

Tiie  treatment  consists  in  making  small  punctures  at  the  most  depend- 
ent part  of  the  tumor,  and  in  subsequently  maintaining  pressure.  Large 
incisions  are  dangerous,  and  unnecessary. 

Encysted  hydi'ocele  of  the  cord  occurs  most  commonly  in  infants.  It 
forms  slowly  and  without  pain,  and  may  reach  the  size  of  an  egg  before 
being  seen  by  the  surgeon.  It  is  distinctly  circumscribed,  round  or  c^val, 
translucent,  firmly  attached  to  the  spermatic  cord,  movable  upon  firm 
traction,  and  not  involving  the  overlying  skin.  It  is  firm  in  consistence, 
and  but  slightly  fluctuating. 

There  is  seldom  more  than  one  tumor,  but  we  sometimes  find  a  series 
of  tumors  extending  from  the  testis  to  the  external  abdominal  ring.  "When 
occurring  in  infancy,  the  lesion  may  result  from  imprisonment  of  a  con- 
genital hydrocele ;  in  adults,  however,  it  originates  in  the  same  manner 
as  do  the  hydroceles  of  the  epididymis.  The  cyst  wall  is  usually  tliin  and 
fibrous,  but  in  chronic  cases  it  becomes  very  thick  and  tough.  Tlie  fluid 
contents  of  the  cyst  are  colorless,  or  have  a  i)ale  straw  color,  and  some- 
times spermatozoa  are  found. 

These  cysts  may  be  seated  at  any  part  of  the  cord  ;  those  of  the  epididy- 
mis are  sometimes  wrongly  considered  cysts  of  the  cord.  AVhen  the  latter 
are  seated  near  the  external  abdominal  ring,  the  diagnosis  may  be  very 
difficult,  otherwise  it  is  generally  easy.  The  character  and  situation  of 
the  tumor,  and  its  mobility  with  the  cord  and  testis,  are  usually  distinc- 
tive. The  danger  of  mistaking  hernia  for  encysted  hydrocele  may  be 
avoided  by  observing  the  uniform  size  of  the  latter,  its  circumscribed  con- 


HYDROCELE    OF    THE    SPERMATIC    CORD.  161 

dition,  its  translucency,  and  the  absence  of  impulse  on  coughing,  and  of 
the  gurgling  characteristic  of  rupture. 

In  children  this  affection  usually  disappears  spontaneously.  The  pro- 
cess of  absorption  may  be  hastened,  if  desirable,  by  counter-irritation 
with  tincture  of  iodine.  Withdrawal  of  the  fluid  and  subsequent  pressure 
sometimes  produces  a  perfect  cure.  Acupuncture  has  been  found  of 
service,  while  incisions  and  the  seton  are  liable  to  cause  excessive  inflam- 
mation. In  very  obstinate  cases,  injection  of  the  tincture  of  iodine  may 
be  resorted  to. 


11 


162  HEMATOCELE, 


CHAPTER    XII. 

HEI^IATOCELE. 

The  term  hematocele  is  applied  to  swellings  of  the  testis  or  of  the  cord, 
caused  by  etfusion  of  blood.  We  shall  adopt  Curling's  division  of  its 
varieties  as  the  best. 

Hematocele  of  the  Testis Hematocele  of  the  testis  may  be  either 

vaginal,  in  which  the  effusion  takes  place  into  the  tunica  vaginalis,  or 
encysted,  when  blood  is  etfused  into  cysts  of  the  testis.  Either  of  these 
forms  may  have  been  preceded  by  hydrocele.  Although  some  authors 
have  doubted  the  occurrence  of  vaginal  hematocele,  independent  of  other 
disease  of  the  parts,  others  are  convinced  that  it  does  take  place  as  a  result 
of  puncture,  blows,  or  any  injury.  Under  such  conditions  it  may  be  called 
traumatic  hematocele  in  distinction  from  the  spontaneous  form,  which  occurs 
in  cases  of  blood  dyscrasia  and  vascular  degeneration  inducing  rupture  of 
the  vessels.  , 

Traumatic  hematocele  is  usually  developed  very  rapidly ;  the  testis  be- 
comes enlarged,  liard,  and  painful,  and  the  scrotum  may  be  ccdematous  or 
the  seat  of  blood -effusion.  There  is  usually  more  or  less  constitutional 
disturbance  and  pain  from  the  tension  of  the  parts.  The  effused  blood 
often  acts  as  a  foreign  body,  causing  suppurative  inflammation.  Again, 
the  blood  may  coagulate  as  it  does  in  aneurism.  Thus  the  course  of  the 
affection  is  sometimes  severe  and,  on  the  contrary,  when  the  effusion  is 
modei'ate,  very  little  ti'ouble  is  experienced. 

The  development  of  spontaneous  hematocele  is  slow  and  unattended 
with  severe  symptoms. 

The  shape  of  the  tumor  in  vaginal  hematocele  is  similar  to  that  of  vagi- 
nal hydrocele,  while  that  of  encysted  hematocele  varies ;  the  testicle  in 
the  latter  being  found  below  the  tumor.  Translucency  is  not  found  in  any 
form  of  hematocele. 

The  diagnosis  of  traumatic  hematocele  is  generally  clear,  the  history  of 
the  case  and  the  local  condition  indicating  its  nature.  The  spontaneous 
variety  is  often  mistaken  for  a  solid  tumor,  and  frequently  the  diagnosis 
can  be  reached  only  by  making  an  exploring  puncture. 

Treatment Ths  patient  must  be  placed  upon  his  back,  the  scrotum 

elevated  and  bathed  with  cooling  lotions.  Free  purgation  is  often  bene- 
ficial, and  anodynes  may  be  required  to  relieve  the  pain.  In  mild  cases 
improvement  begins  in  a  few  days,  and  but  little  suffering  is  experienced. 
In  other  cases  the  effusion  continues,  and  the  tension  must  finally  be  re- 
lieved by  puncture.     The  contents  of  the  cavity  should  be  completely 


HEMATOCELE.  163 

drawn  off,  and  the  scrotum  be  well  suspended.  Should  the  cavity  become 
refilled,  the  operation  must  be  repeated.  In  some  cases,  after  entire  cessa- 
tion of  the  inflammation,  iodine  may  be  injected  as  in  hydrocele.  When 
the  clots  are  very  firm,  it  may  be  necessary  to  make  a  free  incision  and 
thoroughly  cleanse  the  cavity  of  the  sac,  antiseptic  precautions  being  ob- 
served in  the  operation  and  in  the  subsequent  treatment. 

Hematocele  of  the  Cord Hematocele  of  the  cord  is  very  rare,  and 

may  occur  in  a  diffused  or  in  an  encysted  form.  Our  knowledge  of  this 
lesion  is  largely  due  to  the  observations  of  Mr.  Pott. 

Diffused  hematocele  occurs  quite  suddenly  from  rupture  of  a  spermatic 
vein  during  violent  exertion,  as  in  lifting  a  heavy  weight,  or  in  conse- 
quence of  a  blow  on  the  parts,  or  during  the  act  of  copulation  (Maunder). 
The  swelling  is  usually  cylindrical,  extending  from  the  upper  part  of  the 
scrotum  to  the  external  ring,  and  may  attain  very  large  proportions.  The 
parts  lying  over  the  tumor  are  unaffected,  unless  the  lesion  is  a  result  of 
contusion. 

The  symptoms  are  sometimes  slight  and  sometimes  severe.  On  palpa- 
tion the  tumor  is  found  to  be  firm,  but  doughy,  with  ill-defined  outlines. 
The  course  of  diffused  hematocele  of  the  cord  is,  under  favorable  circum- 
stances, towards  gradual  subsidence  ;  in  some  instances  severe  inflamma- 
tory action  is  set  up.  Ultimately  the  cord  is  left  in  a  normal  condition, 
or  perhaps  a  little  thickened. 

The  diagnosis  of  this  affection  usually  offers  no  difiiculty.  The  history, 
position,  and  general  features  of  the  swelling  are  unmistakable.  An  im- 
portant point  is  the  absence  of  impulse  on  coughing. 

Encysted  hematocele  of  the  cord  is  very  rare,  and  is  due  to  eft\ision  of 
blood  into  a  cyst  in  consequence  of  injury. 

Treatment The  first  indications  are  to  prevent  inflammation  by  the 

use  of  the  ordinary  methods.  Subsequently  puncture  followed  by  pressure 
will  effect  a  cure. 


164     •  VARICOCELE 


CHAPTER    XIII. 

VARICOCELE. 

The  term  varicocele  is  used  to  denote  a  varicose  condition  of  the  sper- 
matic veins.  Usually,  it  is  a  very  mild  aflfection,  and  occurs  on  an  average 
in  about  ten  per  cent,  of  all  male  subjects.  It  is  developed  slowly  and  pain- 
lessly, and  the  first  discovery  of  the  patient  is  a  mass  within  the  scrotum 
which  presents  the  sensation  of  a  bundle  of  worms.  In  many  cases  this 
increase  in  the  size  of  the  veins  is  very  slight  and  scarcely  worthy  of  at- 
tention ;  in  others,  it  is  so  large  as  to  constitute  a  serious  deformity.  Again, 
in  exceptional  instances  the  development  of  varicocele  is  more  rapid,  and 
attended  with  more  or  less  discomfort.  The  symptoms,  even  in  well- 
marked  cases,  vary  within  considerable  limits  ;  while  some  patients  seem 
to  suffer  no  inconvenience,  others  complain  of  a  dull  aching  and  dragging 
sensation,  and  some  also  suffer  from  pain  in  the  groin,  loins,  and  even  in 
the  lumbar  region.  These  sensations  are  most  commonly  experienced 
during  walking  or  active  exercise,  and  they  wholly  cease  when  the  patient 
lies  down.  As  a  general  rule,  varicocele  occurs  only  on  the  left  side, 
tliough  some  enlargement  and  tortuosity  has  been  found  in  the  veins  of  the 
right  side.  Various  reasons  are  given  for  the  constancy  of  occurrence  of 
varicocele  on  the  left  side.  The  main  cause  probably  lies  in  the  fact  tluit 
the  left  spermatic  vein  empties  at  right  angles  into  the  corresponding  renal 
vein.  Further,  the  left  spermatic  vein  may  sometimes  be  pressed  upon 
by  the  sigmoid  flexure  distended  by  fecal  accumulation.  "Whether  our 
modern  method  of  dressing  has  any  influence  in  causing  enlargement  of 
the  veins  of  the  left  side  of  the  scrotum  is  yet  an  unsettled  question. 
Certainly,  any  tumor  in  the  groin,  particularly  when  seated  in  or  near  the 
external  ring,  is  liable  to  press  on  these  veins  and  produce  varicocele. 
Various  other  causes  have  been  thought  to  induce  this  condition.  For 
instance,  it  is  stated  by  some  authors  that  ungratified  sexual  desire,  ex- 
cessive venery  and  masturbation  are  important  fjxctors  in  its  cause.  Our 
own  opinion  is  that  as  predisposing  causes  these  perhaps  may  be  considered 
as  vSoraewhat  influential,  since  any  condition  w  hich  tends  to  induce  engorge- 
ment of  the  spermatic  vessels  is  of  course  liable  to  aggravate  this  condi- 
tion and  perhaps  even  to  lead  to  its  development.  In  our  own  experience 
we  liave  usually  seen  the  mild  congestion  of  the  spermatic  veins  of  conti- 
nent young  men  speedily  pass  away  after  marriage.  Varicocele  very  often 
occasions  more  or  less  mental  suffering  to  some  patients  afflicted  with 
it.  Some  regard  it  as  the  result  of  masturbation  practised  in  early  years, 
and  fear  that  it  will  ultimately  lead  to  impotence,  while  in  others  again 
its  existence  causes  the  most  gloomy  thoughts,  which  sometimes  end  in 


TREATMENT. 


165 


well  marked  hypochondriasis.  Varicocele  is  an  affection  mostly  seen  in 
young  men,  and  it  rarely,  if  ever,  occurs  in  the  later  years  of  life.  In 
some  rare  instances  it  coexists  with  a  varicose  condition  of  the  veins 
of  the  legs,  but  the  latter  condition  very  frequently  occurs  without  vari- 
cocele. The  affection  consists  in  excessive  development  of  the  veins, 
the  walls  of  which  become  thickened  by  cell  increase,  and  are  subse- 
quently the  seat  of  fatty  change,  and,  in  some  cases,  even  of  calcareous 
degeneration.  Phlebolites  are  sometimes  found  within  them,  while  in 
general  their  valves  are  wholly  eflfaced,  and  their  M-alls  much  thinned. 
Certain  secondary  changes  in  parts  in  connection  with  the  spermatic 
veins  often  follow  varicocele.  For  instance,  under  the  influence  of  the 
presence  of  the  venous  tumor  the  scrotum  sometimes  becomes  more  or 
less  redundant  and  relaxed,  and  its  walls  are  much  thinned.  In  such  in- 
stances the  power  of  the  ductor  muscle  is  more  or  less  impaired.  Further, 
in  very  chronic  cases,  atrophy  of  the  testes  is  a  not  uncommon  sequela, 
while  early  in  the  course  of  varicocele  it  is  not  unusual  to  find  a  slightly 
congested  condition  of  this  organ,  due  of  course  to  the  impediment  to  the 
return  circulation.  As  a-  result  of  these  changes  it  often  happens  that 
ultimately  the  testicle  grows  gradually  smaller  until  in  some  cases  it  is 
reduced  to  the  size  of  a  pea,  and  sometimes  it  seems  wholly  absorbed. 
Hydrocele  is  another  not  infrequent  complication,  but  it  is  always  of  a  sub- 
acute character,  and  usually  not  very  extensive. 

The  diagnosis  of  varicocele  offers  no  difficulties  whatever,  as  the  most 
superficial  examination  reveals  the  worm-like  mass  within  the  scrotum. 

Treatment The  treatment  of  varicocele  is  either  palliative  or  radical. 

The  former  consists  simply  in  the  use  of  means  which  relieve  the  patient  tem- 
porarily of  the  inconveniences  of  the  affec- 
tion. Of  these  the  most  important  is  the 
use  of  a  properly  fitting  suspensory  band- 
age, by  which  the  scrotum  is  kept  up. 
One  of  the  best  forms  of  suspensory  is 
that  devised  by  the  late  Mr.  Morgan  of 
Dublin.  "  This  consists  of  a  piece  of 
webbing  A^  inches  long,  o-^  inches  wide 
at  one  end,  4  inches  at  the  other,  and 
gradually  tapering  to  the  narrower  end. 
A  piece  of  thick  lead  wire  is  stitched  in 
tlie  rim  of  the  smaller  end,  two  tapes 
sewn  along  the  entire  length  of  the  web- 
bing, and  the  sides  furnished  with  neat 
hooks,  a  lace  and  a  good  tongue  of  chamois  leather.  When  the  suspender 
has  been  j,pplied  to  the  testicle  the  tapes  are  to  be  attached  to  an  abdomi- 
nal belt.  The  size  may  vary  more  or  less.  The  lead  wire  encircling  the 
lower  end  gives  a  foundation  to  the  general  means  of  support  and  keei)S 
the  testes  within  the  bag ;  the  patient  can  mould  it  more  or  less  to  his 
convenience,  and  it  need  not  be  worn  at  night."  Much  benefit  results  from 
frequent  bathing  of  the  parts  in  cold  water,  and  in  all  cases  constipation 


Fig.  40. 


Morgan's  suspender. 


166 


VARICOCELE. 


must  be  avoided.  Whereas  in  many  cases  these  simple  measures  are  suffi- 
cient, there  are  some  which  require  surgical  intert'erence.  The  most 
varied  procedures  have  been  recommended  for  the  relief  of  this  condition, 
but  we  shall  only  mention  those  which  are  most  efficacious,  and  attended 
with  the  least  danger  and  trouble,  for  with  many  of  them  there  is  a  certain 
amount  of  risk.  Since  the  introduction  of  antiseptic  methods  in  surgery 
tlie  old  operation  of  excision  of  a  portion  of  the  vein  has  been  revived. 
This  consists  in  the  removal  of  about  an  inch  of  the  vessel  just  below  the 
external  ring,  after  the  application  of  a  ligature  of  carbolized  cat-gut 
above  and  below  the  part  excised.  This  operation,  however,  even  when 
thus  performed,  is  not  always  successful,  and  is  sometimes  attended  with 
bad  results.  The  operations  of  Ricord  and  Vidal  are  now  never  used. 
The  aim  of  all  operations  is  the  occlusion  of  the  veins,  which  is  very  often 
accomplished  in  a  perfect  manner  by  a  procedure  advocated  by  Mr. 
Henry  Lee,  and  which  is  performed  as  follows:  grasping  the  scrotum  of 
the  aifected  side,  we  easily  eliminate,  owing  to  its  cord-like  feel,  the  vas 
deferens,  and  insert  the  ends  of  the  forefinger  and  thumb  behind  the  bundle 
of  veins — thus  bringing  a  scrotal  fold  together,  through  which  a  needle  is 
passed  and  then  a  figure-of-eight  ligature  quite  firmly  applied  over  it,  not 
so  tightly,  however,  as  to  cut  the  skin.  A  second  needle  is  passed  through 
the  scrotum  in  the  same  manner  about  an  inch  lower  down,  and  then  the 
veins  are  divided  subcutaneously  with  a  tenotomy  knife.  This  incision 
may  be  done  at  the  same  time  that  the  needles  are  inserted,  or  a  day  or 
two  later.  This  operation  has  the  confidence  of 
many  prominent  surgeons  especially  in  England. 
Another  operation  has  been  performed  by  j\lr. 
John  Wood  of  King's  College,  London.  This 
consists  simply  in  the  introduction  subcutane- 
ously of  a  double  wire  noose,  while  compression 
is  produced  by  a  metallic  spring  until  division 
occurs.  This  operation  has  been  modified  by 
Dr.  R.  F.  Weir,  of  New  York,  and  will  be  best 
understood  by  reference  to  the  accompanying 
figure.  Dr.  Weir's  assistant  says  :  "In  Wood's 
operation,  tension  upon  the  wire  passed  around 
the  veins  is  made  by  a  spring  shaped  like  a 
horse-shoe,  one  arm  of  which,  by  means  of  a 
short  foot-piece,  rests  against  the  scrotum,  and 
through  it  the  wires  pass  to  be  attached  to  the 
other  arm  of  the  spring.  The  effiict  of  the 
pressure  is  to  bury  the  foot-piece  in  the  tissues 
of  the  scrotum  and  to  give  rise  to  an  abscess. 
To  secui-e  the  same  traction  upon  the  encircling 
wires.  Dr.  Weir  uses,  it  will  be  seen,  a  steel 
bent  spring,  the  ends  of  which  do  not,  however,  touch  the  scrotum,  but 
stretch,  by  its  elasticity,  wires  (c  c)  passed  after  Ricord's  method  around 
the  veins  (f).     Moi*eover,  instead  of  leaving  the  wire  in,  as  suggested  by 


Fig.  41. 


Weir's  varicocele  spriag. 


TREATMENT.  167 

"Wood,  until  it  cuts  its  way  out,  it  has  been  found  by  experience  best,  after 
eight  or  ten  days,  to  remove  the  wires,  as  by  that  time  a  sufficient  amount 
of  inflammatory  action  will  have  been  excited  to  obliterate  the  veins  satis- 
factorily. Inasmuch  as  this  removal  is  attended  at  times  with  considerable 
difficulty,  Dr.  Weir  has  adopted  the  plan,  which  originated  at  St.  Luke's 
Hospital,  of  passing  a  reserve  wire  (d)  through  one  of  the  loops  before  the 
latter  is  di'awn  around  the  veins,  so  that  when  the  encircling  wire  of  one 
side  is  cut  loose  from  the  spring,  the  imbedded  portion  can  be  readily  with- 
drawn from  the  other  side  by  means  of  this  same  reserve  wire,  and  then 
the  remaining  wire,  being  thus  set  free,  can  also  be  removed  without  diffi- 
culty." 

In  the  cases  thus  treated  the  wires  were  in  this  Avay  removed  on  the 
seventh  and  eighth  days  respectively,  with  satisfactory  results,  as  the  pa- 
tients have  been  examined  since  and  no  relapse  has  occurred.  Another 
metliod  of  treatment  advocated  by  Dr.  Weir  is  rather  more  simple,  and  is 
performed  as  follows  :  A  small  incision  having  been  made  at  the  upper 
part  of  the  scrotum,  a  ligature  of  carbolized  catgut  is  passed  around  the 
veins,  avoiding  the  other  parts,  and  brought  out  of  the  same  opening  and 
then  tied  and  cut  off  short.  This  ligature  being  left  in  place,  the  wound 
is  treated  very  carefully  by  the  antise})tic  method  and  heals,  leaving  the 
veins  thus  tlioroughly  obliterated,  and  the  ligature  is  absoi'bed. 

A  very  simple  operation  has  been  used  by  Prof.  T.  M.  Markoe,  and 
for  many  years  has  been  attended  with  success  and  never  with  any  bad 
result.  It  is  performed  as  follows :  Grasp  the  cord  well  above  the  mass  of 
enlarged  veins  and,  separating  with  the  finger  and  thumb  the  vas  deferens 
from  the  vein-trunks,  pass  a  good-sized  needle,  armed  with  silver  wire, 
between  the  vas  and  the  veins,  bringing  out  the  needle  on  the  back  part  of 
the  scrotum.  Drawing  the  wire  partly  through,  return  the  needle  by  the 
same  opening,  passing  it  now  from  the  back  to  tlie  front  and  outside  of 
both  vas  and  veins,  and  bringing  it  out  on  the  front  at  the  point  of  entrance. 
By  drawing  on  the  wire  we  have  the  veins  surrounded  by  a  loop  from 
which  the  vas  has  been  excluded.  A  piece  of  sheet  lead  of  an  oval  form, 
two  inches  long  and  one  inch  wide,  made  very  smooth  at  its  edges  and 
bent  sliglitly  concave  in  its  long  diameter,  so  as  to  apply  itself  to  the 
neck  of  the  scrotum,  should  be  ready,  with  a  good-sized  hole  in  its  centre 
through  which  the  wires  are  to  be  passed,  care  being  taken  that  the 
wires  do  not  cross  each  other.  A  roll  of  sticking  plaster  about  an  inch 
long  and  as  large  as  a  quill  should  now  be  laid  on  the  outside  of  the  lead 
plate,  so  that  the  wires  can  be  drawn  and  twisted  over  it.  By  drawing 
well  home  the  loop  of  wire  and  twisting  it  over  the  roll  of  adhesive  plaster, 
tlie  veins  are  firmly  inclosed,  and  the  force  of  compression  can  be  increased 
from  day, to  day  by  further  twisting  of  the  wire.  As  this  twisting  process, 
however,  is  apt  to  break  the  wire  if  carried  loo  far  or  repeated  too  often, 
it  is  better  to  use  a  small  wedge  of  pine  wood  above  and  below  the  wire, 
pushed  in  between  the  lead  and  the  roll  of  sticking  plaster.  By  this 
means  all  necessary  pressure  is  secured;  the  veins  can  be  obliterated  in  a 
few  days  and  the  wires  remov(;d,  or  the  [)ressure  can  be  kept  up  for  ten  or 


168 


VARICOCELE. 


fifteen  day»,  within  wliich  time  the  wire  will  probably  cut  through.  Either 
plan  is  effectual,  init  as  tlie  apparatus  usually  gives  no  pain  and  excites  no  in- 
flanunation,  it  is  perhaps  better  to  let  tlie  wires  cut  through.  The  removal 
of  the  wires  is  perfectly  easy  if  care  has  been  taken  not  to  cross  them  in 
passing  them  through  the  lead  plate. 

Of  late  years  the  operation  originally  advocated  by  Sir  Astley  Cooper, 
of  ablation  of  a.  portion  of  the  scrotum,  has  found  favor  with  some  of  the 
prominent  New  York  surgeons,  particularly  in  the  cases  of  varicocele  com- 
plicated with  redundancy  of  the  scrotum.  For  the  performance  of  this 
operation  we  require  a  pair  of  clamps  and,  in  an  emergency,  the  straight 
blades  of  a  long  and  heavy  pair  of  scissors  will  suffice.  Tbe  best  instru- 
ment, bowever — and  there  are  several  clamps  used — is  that  devised  by  Dr. 
Henry,  and  called  the  scrotal  forceps.  It  consists  of  two  double  curved 
blades  made  of  steel,  ten  inches  long,  sufficiently  heavy  to  give  strength 
and  admit  of  pressure  without  injury.  The  handles  are  large  enough  to 
admit  the  finger  and  thumb  readily.  The  lower  half  of  the  instrument 
below  the  joint  is  fenestrated  in  both  blades  ;  the  coapting  surfaces  are 
evenly  notched  to  prevent  tlie  parts  from  slipping.     The  fenestra  aftbrd  the 

Fiff.  42. 


Scrotal  clamp. 


surgeon  the  facility  of  inserting  all  the  ligatures  before  dividing  the  parts, 
if  he  so  desires.  The  thickness  of  the  upper  blade  from  the  line  of  inser- 
tion of  the  ligatures  leaves  ample  tissue  for  healing  to  take  place  before 
they  cut  through.  The  curve  of  the  blades  is  that  necessary  to  be  given 
to  the  incision,  which  must  he  rounded  at  tlie  ends,  otherwise  there  are 
two  teat-like  prominences.  The  screws  are  sufficiently  heavy  to  give  firm- 
ness and  evenness  of  pressure.  The  extra  blade  is  made  of  steel,  nickel- 
plated,  and  is  maintained  in  the  lower  blade  of  the  forceps  by  two  small 
pins  and  the  slight  tension  put  on  the  spring  of  the  metal.  It  is  easily 
inserted  and  as  readily  thrown  off  by  elevation  with  the  thumb-nail.  The 
mode  of  operation  is  very  simple.  It  is  well  to  first  adapt  the  forceps 
when  the  patient  is  in  the  erect  position,  as  a  better  idea  is  gained  of  the 
amount  of  scrotum  to  be  excised  and  of  the  proposed  line  of  incision.  Care 
must  be  taken  that  only  the  scrotum  is  included  between  the  blades.  An 
anaesthetic  having  been  given,  the  forceps  are  held  in  the  median  line, 
and  tlie  parts  are  cut  off  on  their  convex  border  by  means  of  a  strong 
pair  of  scissors  curved  on  the  flat.     The  object  of  the  extra  blade  is  to 


TREATMENT.  169 

leave  a  small  rim  of  scrotal  tissue,  beyond  tlie  blade  proper,  in  which  the 
continuous  suture  maybe  applied.  In  our  experience  this  amount  of  tissue 
does  not  allow  the  sutures  to  be  placed  deeply  enough,  a  point  which  must 
never  be  forgotten,  since  the  traction  of  the  ductor  muscle  is  considerable 
and  the  success  of  the  operation  depends  largely  upon  the  continuous  coap- 
tation of  the  lips  of  the  wound.  It  is  well,  therefore,  to  always  use  the  extra 
blade  and  insert  the  sutures-busing,  preferably,  the  interrupted — about 
half  an  inch  apart,  after  the  patient  is  anaesthetized  and  before  the  ablation 
is  performed.  Care  must  be  taken  to  check  hemorrhage ;  to  prevent  it, 
the  operation  should  not  be  huri'iedly  performed,  and  the  patient  should 
be  watched  for  some  time  afterwards.  In  general,  acupressure  needles 
and  serre-Jines  are  the  only  appliances  necessary  to  control  hemorrhage. 
After  the  operation,  a  band  of  adhesive  plaster  may  be  applied  around 
the  base  of  the  scrotum,  while  a  number  of  narrow  strips  of  the  same, 
about  two  inches  long,  may  be  placed  between  the  sutures.  Then,  the 
parts  being  supported  by  a  pad  of  oakum,  which  is  renewed  from  time 
to  time,  the  wound  may  be  covered  with  a  strip  of  lint  saturated  in  a  ten 
per  cent,  solution  of  carbolic  acid.  The  subsequent  treatment  is  upon 
general  principles.  In  favorable  cases  union  occurs  by  first  intention 
within  a  few  days,  while  in  other  cases  it  is  delayed  as  long  as  a  fort- 
night. Occasionally  the  healing  process  is  attended  with  certain  compli- 
cations such  as  a  varying  amount  of  infiltration  of  serum  or  blood  into  the 
scrotal  tissues,  or  one  or  more  abscesses.  Secondary  hemorrhage  may  also 
occur,  and  occasionally  causes  considerable  trouble.  Erysipelas  rarely 
occurs  when  the  operation  is  done  upon  a  healthy  subject,  though  it  is  to 
be  feared  in  persons  suffering  from  any  constitutional  dyscrasia,  such  as 
Bright's  disease  and  chronic  alcoholism.  Of  course  such  an  operation  is 
wholly  inadmissible  in  patients  in  the  early  and  active  stages  of  syphilis 
and  in  those  of  the  hemorrhagic  diathesis.  Surgeons  are  not  of  one  mind 
as  to  the  final  result  of  this  operation :  some  think  it  merely  pallii^tive, 
others  radically  curative.  Our  own  opinion  is  that  in  most  cases  it  pro- 
duces a  cure,  while,  in  some,  subsequent  elongation  of  the  scrotum  certainly 
does  occur.  The  propriety  of  performing  it,  therefore,  depends  upon  the 
nature  of  the  case  and  other  circumstances  connected  with  it. 


110  GONORRHCEAL    PROSTATITIS. 


CHAPTER    XIV. 
GONORRHCEAL    PROSTATITIS. 

Acute  Prostatitis. 

Acute  prostatitis  may  be  due  to  violence  from  sounds,  catheters,  or 
litliotrity  instruments;  to  the  application  of  caustics  to  the  deeper  portions 
of  the  urethra;  to  stricture,  the  irritation  of  a  stone  in  the  bladder,  or  a 
fragment  of  a  stone  impacted  in  the  prostatic  urethra ;  to  immoderate 
coitus,  or  excessive  purgation;  yet  by  far  the  most  frequent  cause  is  ure- 
thral gonorrhoea. 

Gonorrha?al  prostatitis  owes  its  origin  to  the  extension  of  the  inflamma- 
tion from  the  urethral  walls  to  the  substance  of  the  prostate  gland ;  it  oc- 
curs, therefore,  at  a  time  when  the  disease  has  invaded  the  deeper  portions 
of  the  canal,  and  is  consequently  rare  during  the  first  two  weeks,  resem- 
bling in  this  respect  its  more  frequent  congener,  gonoi'rhceal  epididymitis. 
The  accessory  causes  of  the  last  mentioned  disease,  viz.,  highly  irritant 
injections,  forcible  distention  of  the  urethra  in  using  a  syringe,  excessive 
exercise,  alcoholic  stimulants,  exposure  to  cold  and  wet,  and  venery,  may 
also  contribute  to  the  production  of  prostatitis.  There  is  little  ground  for 
believing  that  this  affection  is  occasioned  by  the  use  of  copaiba  and  cubebs, 
although  the  contrary  has  been  asserted. 

If  we  inquire  into  the  pathology  of  this  affection,  we  shall  find  that  the 
first  effect  of  the  gonorrhceal  inflammation  was  exercised  upon  the  mucous 
membrane  of  the  prostatic  urethra,  and  upon  the  underlying  cellular  tissue 
surrounding  the  gland.  In  this  manner  the  size  of  the  organ  is  increased ; 
it  encroaches  upon  the  urethra  and  interferes  with  the  passage  of  the  urine; 
it  may  be  felt  to  be  of  unusual  dimensions  by  examination  per  anum,  when 
its  sensitiveness  will  also  be  noticed.  The  inflammation  next  involves  the 
prostatic  follicles,  whose  secretion  is  thereby  increased  and  takes  the  place 
in  a  great  measure  of  the  urethral  discharge  from  the  meatus,  which  dimin- 
ishes or  entirely  disappears  on  the  occurrence  of  the  prostatitis.  The 
prostatic  secretion  is  readily  recognized  by  its  thin,  viscid,  white-of-an-egg- 
likc;  character. 

If  the  inflammation  proceed  to  the  suppurative  stage,  a  number  of  these 
follicles,  or  perhaps  all  of  them,  become  filled  with  pus  distending  their 
walls,  and  as  many  little  abscesses  ai'e  formed  as  there  are  follicles  involved, 
which  may  subsecpiently  coalesce  and  unite  into  one  single  abscess,  with 
dimensions  corresponding  to  the  greater  or  less  amount  of  the  organ  in- 
vaded. There  is  never,  tiien,  at  the  outset  one  abscess  of  considerable 
size.     Such  occurs  only  by  the  coalescence  of  a  number  of  small  ones 


SYMPTOMS.  Ill 

seated  in  the  follicles.  Meanwhile,  the  muscular  tissue,  which  constitutes 
so  large  a  portion  of  the  prostate  gland,  is  unaffected,  except  that  it  is 
in  a  constant  state  of  contraction,  thereby  inducing  urethral  and  rectal 
tenesmus. 

The  prostate  is  most  intimately  related  anatomically  with  the  urethra, 
and  it  is  into  this  passage,  therefore,  that  an  abscess  most  frequently  breaks, 
sometimes  by  one,  sometimes  by  several  openings.  If  only  a  portion  of 
the  organ  has  been  involved,  the  remainder  may  retain  its  integrity;  the 
entrance  of  urine  into  the  cavity  does  not  appear  to  be  attended  with  the 
evil  consequences  which  have  been  feared.  The  evacuation  and  closure  of 
the  abscess  leave  a  cicatrix,  and  the  function  of  the  gland  may  eventually 
be  unimpaired.  It  will  be  observed  that  under  these  circumstances — a 
prostatic  abscess  opening  only  into  the  urethra — the  abscess  is  confined 
within  the  fibrous  capsule  of  the  gland,  and  is  from  first  to  last  strictly 
intra-prostatic. 

Far  otherwise  is  it  when  the  abscess  breaks  in  any  other  direction,  for 
then  the  suiTOunding  cellular  tissue  is  infiltrated;  and  we  have  besides  an 
intra-prostatic  a  peri-prostatic  abscess,  capable  of  much  greater  mischief 
than  the  former.     But  of  this  more  anon. 

Symptoms — The  earliest  symptom  of  an  attack  of  prostatitis  is  com- 
monly a  sensation  of  Aveight  or  a  dull  pain  in  the  perinasum.  There  is  not 
that  vesical  tenesmus  which  we  find  in  cystitis,  but  the  exit  of  the  urine 
is  obstructed  by  the  swollen  gland,  and  the  calls  to  micturate  will  be  fre- 
quent and  urgent  sim})ly  because  the  bladder  is  never  fully  emptied  of  its 
contents,  and  a  short  time  suilices  to  fill  it  to  distention.  The  stream  is 
generally  quite  small,  is  only  forced  out  by  prolonged  straining,  and  ex- 
excites  a  severe  scalding  sensation  in  the  deeper  portion  of  the  canal. 
Complete  retention  of  urine  often  occurs,  requiring  the  use  of  the  catheter. 
The  bowels  are  commonly  constipated,  although  the  patient  is  constantly 
led  by  a  feeling  of  fullness  in  the  rectum  to  make  fruitless  efforts  at  stool ; 
and  should  del'ecation  take  place,  the  act  excites  severe  pain.  The  system 
at  large  sympathizes  with  the  local  trouble,  and  general  febrile  excitement 
ensues.  Exploration  of  the  prostate  by  the  finger  in  the  rectum  I'eveals 
abnormal  sensibility,  increase  of  temperature,  and  tumefaction  of  this  organ 
proportioned  to  the  severity  of  the  disease.  On  attempting  to  introduce  a 
catheter,  it  meets  with  an  obstruction  in  the  prostatic  urethra,  and,  before 
entering  the  bladder,  its  point  deviates  to  one  side  or  the  other  in  an  op- 
posite direction  from  the  lobe  of  the  organ  involved.  If  the  middle  por- 
tion of  the  prostate  is  the  chief  seat  of  the  inflammation,  the  introduction 
of  a  catheter  may  be  impossible  or  can  only  be  effected  by  force.  Both 
rectal  and  urethi-al  exploration  are  attended  with  extreme  suffering  to  the 
patient. 

A  majority  of  cases  of  acute  prostatitis  terminate  in  resolution;  the 
minority  in  supjjuration.  The  formation  of  matter  is  not  always  announced 
l)y  well  marked  symptoms,  but  may  be  strongly  suspected  if,  after  the  dis- 
ease has  been  increasing  in  intensity  for  eight  or  ten  days,  the  patient  is 
seized  with  repeated  chills  followed  by  fever  and  general  depression.     It 


172  GONORRHCEAL    PROSTATITIS. 

is  possible,  however,  for  an  abscess  to  form  witliout  aflfording  the  least 
reason  to  suspect  it.  A  case  occurred  at  St.  George's  Hospital,  under  the 
care  of  Dr.  Pitman,  in  which  prostatitis  supervened  upon  an  attack  of 
gonorrhcea,  and  terminated  in  suppuration  and  death  of  the  patient,  with 
entire  absence  of  rigors  and  the  ordinary  symptoms  of  abscess.  At  the 
post-mortem  examination,  an  extensive  abscess,  which  had  not  been  sus- 
pected during  life,  was  found  between  the  bladder  and  rectum.^ 

If  the  abscess  be  deeply  seated  in  the  gland,  tending  to  point  towards 
the  rectum,  a  soft  fluctuating  tumor  can  be  felt  in  the  region  of  the  pros- 
tate by  the  finger  introduced  into  the  gut,  especially  if  the  gland  be  im- 
movably fixed  by  a  sound  in  the  urethra.  An  abscess  in  the  neighborhood 
of  the  urethra  is  more  difficult  of  detection,  except  from  its  encroachment 
upon  the  canal,  and  its  interference  with  the  exit  of  urine  and  the  intro- 
duction of  a  catheter. 

A  prostatic  abscess  most  frequently  breaks  upon  the  side  of  the  urethra 
during  the  efforts  of  the  patient  to  expel  the  urine  or  feces,  or  it  is  often 
perforated  by  the  point  of  an  instrument  introduced  for  the  purpose  of  ex- 
ploration or  catheterization.  With  the  bursting  of  the  abscess,  the  patient 
experiences  delightful  relief  from  his  sufferings ;  his  urine  once  more  flows 
naturally,  and  his  febrile  symptoms  soon  disappear. 

In  those  cases  before  referred  to,  in  which  the  rupture  takes  place  in 
another  direction  than  the  urethral,  the  point  of  exit  of  the  matter  varies. 
Sometimes  it  opens  into  the  bladder,  probably  when  the  peri-prostatic 
abscess  is  seated  chiefly  above  and  behind  the  prostate.  Its  escape  into 
the  rectum  is,  however,  more  frecpient;  and  although  this  event  is  much 
less  favorable  than  a  urethral  opening,  since  it  allows  of  the  entrance  of 
fecal  matter  from  the  gut,  and  although  a  rectal  fistula  may  remain  ibr 
some  time,  yet  the  latter  accident  is  rare,  and  these  cases  usually  turn  out 
well  in  the  end.  Sometimes  communication  is  established  both  with  the 
bladder  and  rectum,  forming  a  recto-vesical  fistula,  in  which  case  the  urine 
may  trickle  into  the  rectum  on  each  act  of  micturition,  and,  if  the  patient 
is  troubled  with  flatus,  the  "  wind"  may  be  heard  gurgling  through  the 
urine  contained  in  tlie  bladder. 

But,  having  gained  access  to  the  ischio-rectal  fossa,  these  abscesses  may 
make  their  way  in  various  directions  and  appear  on  the  surface  at  points 
far  distant  from  the  seat  of  their  origin.  Thus  the  matter  may  point  in 
the  perinieum,  or  extend  to  the  scrotum,  and  even  to  the  sheath  of  the 
penis.  Guyon  reports  one  case  in  which  the  abscess  pointed  in  the  left 
thigh,  and  another  just  below  the  false  ribs.  I  had  a  case  in  which  pros- 
tatitis was  set  up  by  the  inti'oduction  of  a  sound  for  seminal  emissions,  and 
fistulous  openings  formed  in  the  perina^um  and  just  below  the  groin.  The 
patient  ultimately  recovered,  married,  and  had  children.  Beraud''  cites  a 
case  in  wiiich  the  pus  followed  the  course  of  the  vas  deferens  and  appeared 
in  the  inguinal  fold. 

1  Lancet,  Lontl.     Am.  ed.,  January,  1861,  p.  69. 

2  Mai.  de  la  prostate,  These,  1857. 


TREATMENT.  1T3 

Diagnosis — Acute  prostatitis  is  chiefly  liable  to  be  confounded  with 
cystitis.  It  is  not  likely  that  any  one  would  confound  prostatitis  with  in- 
flammation of  Cowper's  glands,  which  presents  such  different  characters. 

Treatment — The  appearance,  during  an  attack  of  gonorrhoja,  of  symp- 
toms of  prostatitis,  should  lead  the  surgeon  at  once  to  abandon  the  use  of 
injections,  and,  neglecting  the  urethral  discharge  for  a  time,  to  direct  his 
whole  attention  to  the  more  serious  affection  which  has  supervened.  The 
patient  should  now  observe  the  most  perfect  rest  and  quietude.  If  the 
symptoms  be  severe,  from  six  to  a  dozen  leeches  may  be  applied  to  the 
perinajum,  and  be  followed  by  a  hot  bath  at  the  temperature  of  one  hundred 
degrees,  which  may  be  repeated  with  benefit  several  times  in  the  twenty-four 
hours.  It  is  very  doubtful,  however,  whether  any  decided  benefit  really 
ensues  from  the  application  of  leeches  either  to  the  perina^'um  or  within  the 
rectum,  as  recommended  by  some  authors.  In  the  intervals  of  the  baths, 
the  perineum  should  be  covered  with  hot  fomentations  or  poultices. 

In  place,  however,  of  the  above  classic  treatment  of  acute  prostatitis  by 
means  of  hot  applications,  the  contrary  course  of  introducing  ice  into  the 
rectum,  as  will  be  mentioned  in  the  next  chapter  on  cystitis,  is  worthy  of 
a  trial.  In  this,  as  in  many  other  affections,  both  heat  and  cold  may  find 
their  appropriate  application. 

Internally  we  may  resort  to  those  remedies,  as  the  salts  of  potash  and 
soda,  which  are  supposed  to  render  the  urine  more  dilute  and  mild  in  its 
character.  A  mixture  of  mucilage,  bicarbonate  of  potash,  and  hyoscya- 
mus,  is  well  adapted  for  the  treatment  of  the  disease  Ave  are  now  consider- 
ing. The  diet  should  be  light,  consisting  of  gruel,  mucilaginous  drinks, 
milk,  and  farinaceous  substances,  at  least  in  the  early  stages  of  the  dis- 
ease ;  at  a  more  advanced  period,  and  after  suppuration  has  taken  place, 
our  utmost  efforts  may  be  required  to  sustain  the  strength  of  the  patient 
by  a  nourishing  diet  and  even  tonics.  The  bowels  should  be  opened  daily 
either  by  warm  enemata  or  by  a  dose  of  castor  oil. 

Sleep  should  be  secured  by  the  exhibition  of  a  Dover's  powder  at  night. 
Mr.  Adams  speaks  highly  of  warm  enemata,  consisting  of  four  or  five 
ounces  of  simple  water  or  gruel,  administered  at  bedtime,  which  are  said 
to  afford  comfort  to  the  patient,  and  to  act  as  a  fomentation  to  the  in- 
flamed gland. 

Complete  retention  of  urine  will  require  evacuation  of  the  bladder  by 
means  of  a  flexible  catheter,  or  pneumatic  aspiration  above  the  pubes. 
When  an  abscess  has  formed  and  fluctuation  can  be  distinctly  felt  by  the 
finger  in  the  rectum,  it  should  be  punctured  through  the  intestinal  wall. 
Tarnowski  prefers  to  make  a  careful  opening  from  the  perinteum,  so  as  to 
avoid  communication  with  the  rectum  and  the  entrance  of  fecal  matter 
into  the  cavity  of  the  abscess.  Diday  also  favors  an  opening  in  this  situa- 
tion. When  the  collection  of  matter  is  most  prominent  towards  the  ure- 
thra, it  may  sometimes  be  opened  by  a  conical  sound  introduced  as  far  as 
tlie  prostatic  portion  of  the  canal,  while  a  finger  within  the  rectum  presses 
the  tumor  against  the  point  of  the  instrument.  This  attempt,  however,  is 
by  no  means  free   from  danger,  and  should  never  be   made,  unless  the 


174  GONORRHCEAL    PROSTATITIS. 

symptoms  are  urgent  and  tlie  existence  of  matter  in  the  neighborhood  of 
the  urethra  is  highly  probable. 

When  the  abscess  has  opened  into  the  rectum,  warm  water  should  be 
injected  after  each  passage  of  the  stools,  so  as  to  remove  any  fecal  matter 
which  may  have  lodged  in  the  fistula,  and  also  to  ftxvor  the  exit  of  the 
puriform  secretion. 

Mr.  Milton  treats  prostatitis  by  the  free  application  of  water,  as  hot  as 
it  can  be  borne,  to  the  perinanim ;  orders  tartar  emetic  in  large  doses,  or, 
if  the  patient  object  to  this,  small  doses  of  calomel  or  hydrargyrum  cum 
creta,  a  sedative  eveiy  night,  rest  in  bed,  and  very  light  diet.  He  believes 
in  the  administration  of  the  iodide  of  potassium  to  get  rid  of  any  hardness 
remaining  after  the  acute  attack. 

1  may  mention  that  iodoform,  given  internally  or  in  form  of  suppository, 
is  also  used  for  the  same  purpose. 

Chronic  Prostatitis. 

An  acute  attack  of  prostatitis  may  subside  into  a  chi'onic  form,  or  the 
latter  may  first  appear  in  the  course  of  a  case  of  gleet,  or  as  a  result  of 
onanism,  excessive  venereal  indulgence,  or  sedentary  habits.  In  its  mildest 
form  it  has  been  described  by  Dr.  Gross'  and  others  under  the  name  of 
"  prostatorrhoja." 

This  afl^ection  is  confined,  at  the  outset  at  least,  to  the  glandular  ele- 
ments of  the  prostate  and  their  excretory  ducts  opening  into  the  neighbor- 
hood of  the  caput  gallinaginis.  The  mucous  membrane  is  thickened,  and 
more  vascular  tlian  natural.  The  openings  of  the  ducts  are  enlarged  and 
filled  with  a  lactescent,  opaline  liquid,  which  is  in  some  cases  mixed  with 
pus.'' 

One  of  the  most  frequent  and  prominent  symptoms  of  this  affection  is  a 
discharge  of  clear  and  transparent,  or  sometimes  turbid,  mucus  from  the 
meatus,  which  is  found  by  the  microscope  to  consist  of,  first,  morphous 
crystals  of  uric  acid,  or  itrnmoniaco-magnesian  phosphates  ;  second,  mucus- 
corpuscles  ;  third,  blood  disks;  and,  fourth,  epithelium  cells,  either  with 
or  without  a  few  pus-corpuscles.  The  discharge  may  be  almost  constant 
in  its  appearance  and  sufficient  in  quantity  to  stain  the  linen;  or  more 
frequently  it  is  forced  from  the  urethra  by  the  pressure  of  the  hardened 
feces  during  straining  at  stool,  and  is  not  perceptible  at  any  other  time. 
Most  patients  suppose  that  it  consists  of  semen,  from  which  it  may  be  dis- 
tino-uished  under  the  microscope  by  the  absence  of  spermatozoa.     Very 

'  N.  Am.  M.-Chir.  Rev.,  Phila.,  .July,  1860.  Dr.  Gross  describes  this  as  a 
hitherto  imknowii  affection  under  the  name  of  "  prostatorrhoea  ;"  but  his  account 
of  it  corresponds  in  almost  every  particuhar  with  that  given  by  Mr.  Adams  under 
the  head  of  "Prostatitis  from  Onanism."  The  increased  secretion  of  prostatic 
fluid  is  a  more  symptom  of  irritation  or  inflammation  of  the  gland,  and  it  is, 
therefore,  desirable  that  the  term  prostatitis  should  be  retained. 

2  Picard,  Mai.  de  la  prostate,  1877. 


CHRONIC    PROSTATITIS  175 

many  of  the  cases  of  spermatorrlioea  so  called  are  doubtless  instances  of  this 
affection. 

In  most  cases,  the  frequency  of  micturition  is  more  oi*  less  increased ; 
the  stream  of  urine  is  ejected  without  force ;  the  last  di'ops  dribble  away, 
or  are  only  expelled  with  considerable  effort,  and  a  scalding  sensation  is 
felt  in  the  urethra  during  and  after  the  act.  Zeissl  ascribes  the  dribbling 
away  of  the  last  drops  of  urine,  and  the  undue  moisture  of  the  meatus  after 
the  act,  to  the  "capillarity  existing  between  the  prostatic  secretion  col- 
lected in  the  urethra  and  the  last  drops  of  urine." 

Pain  and  uneasy  sensations  are  experienced  in  the  perinteum,  thighs, 
and  lumbo-sacral  regions ;  there  is  often  great  irritation  about  the  anus 
attended  by  hemorrhoids  or  eczema  ;  the  bowels  are  constipated,  and  defe- 
cation difficult  and  painful;  the  passage  of  an  instrument  into  the  bladder 
excites  severe  pain  as  it  passes  through  the  prostatic  region ;  on  examina- 
tion per  anum,  the  gland  is  found  to  be  tumefied,  sensitive  on  pressure, 
and  sometimes  indurated.  The  patient  is  irritable  and  low-spirited ;  is 
incapable  of  mental  or  physical  exertion ;  suffers  from  weakness,  head- 
ache, and  dyspepsia ;  watches  his  symptoms  with  the  greatest  anxiety ; 
imagines  that  he  is  losing  his  memory,  that  he  is  impotent  or  affected  with 
syphilis,  and  in  short  becomes  a  desperate  hypochondriac. 

Independently  of  its  action  upon  the  nervous  system,  chronic  prostatitis 
is  not  a  serious,  although  a  very  obstinate,  disease,  often  persisting  for 
years.  During  its  continuance,  the  patient  is  especially  exposed  to  acute 
inflammation  of  the  prostate  in  consequence  of  excesses  of  any  kind  or  of 
a  fresh  attack  of  clap  ;  otherwise  chronic  prostatitis  rarely  terminates  in 
suppuration.  By  its  long  duration,  however,  the  mucous  membrane  of 
the  vesical  neck  may  become  involved,  giving  rise  to  frequent  calls  to 
urinate,  attended  with  straining,  and  the  exit  of  blood  at  the  close  of  the 
act  as  in  gonorrhoeal  cystitis.  Still  further,  in  consequence  of  this  constant 
straining,  the  muscular  portion  of  the  prostate  may  become  hypertrophied 
in  whole  or  in  part,  resulting  in  an  increase  in  the  size  of  the  organ  similar 
to  that  which  takes  place  in  old  age;  one  or  the  other  lobe  or  the  whole 
prostate  acquires  a  hard,  almost  stone-like  consistency,  and,  on  post-mortem 
examination,  its  tissue  is  found  to  be  traversed  by  whitish,  tense,  and  tough 
fibrous  bands,  while  the  glandular  elements  seem  to  have  disappeared 
through  atrophy.  (Zeissl.) 

Mr.  Ledwich^  had  an  opportunity,  in  two  instances,  of  becoming  ac- 
quainted with  the  pathology  of  this  affection  :  "  One  case  occurred  at  the 
age  of  eighteen,  the  second  at  thirty  ;  botli  were  well  marked  examples  of 
the  disease,  and  succumbed  to  phthisis,  but  this  latter  had  no  connection 
with  the  uretliral  affection.  The  prostato-vesical  plexus  was  full,  and 
many  of  it*  branches  varicose ;  the  capsule  of  the  prostate  adhered  inti- 
mately to  its  surface,  and,  on  slicing  the  gland,  it  seemed  soft,  with  large, 
open,  venous  l)ranches  on  the  section,  from  wliich  blood  exuded,  whilst 
the  whole  gland  exhibited  an  augmented  volume ;  the  mucous  membrane 

'  Dublin  Q.  J.  M.  Sc,  Aug.  1,  1857.  p.  30. 


1T6  GONORRH(EAL    PROSTATITIS. 

of  its  urethral  aspect  was  red,  soft,  thickened,  and  viUous,  whilst  the  ducts 
could  be  distinguished  witli  tlie  unassisted  eye  ;  the  uvula  and  trigonum 
vesicaj  were  red  and  turgid,  but  the  remainder  of  the  bladder  was  liealthy. 
I  examined  with  some  anxiety  for  the  presence  of  tubercular  deposit  in 
the  gland,  but,  although  this  morbid  condition  was  often  anticipated,  no 
evidence  of  any  such  structural  lesion  could  be  detected.  The  seminal 
ducts  did  not  present  any  alteration  as  to  size,  their  excretory  orifices 
being  discovered  with  the  greatest  difficulty,  the  vesiculai  seminales  being 
full  and  swollen,  but  without  any  other  abnormal  appearance ;  scrofulous 
tubercles  existed  in  the  epididymis,  yet  the  testicles,  although  soft  and 
small,  were  otherwise  healthy." 

M.  Bouloumie,^  in  numerous  autopsies,  "  has  found  especially  dilatation 
of  the  prostatic  glands  and  numerous  calculi  of  concentric  stratification, 
but  no  muscular  hypertrophy.  Guerlain^  mentions  increased  density  and 
cohesion  of  the  cellular  tissue  surrounding  the  gland,  which  he  has  seen 
infiltrated  with  pus  forming  an  abscess  around  the  organ,  as  also  noticed 
by  Sir  Henry  Thompson.   (Picard.) 

Treatment In  most  cases  of  chronic  prostatitis,  the  patient  is  laboring 

under  a  combination  of  mental  as  well  as  physical  symptoms,  and  the 
treatment  must  be  directed  to  tlie  mind  equally  with  the  body.  It  is  not 
sufficient  in  these  cases  to  dash  off  a  hurried  prescription  and  dismiss  the 
patient  after  five  minutes'  conversation.  The  victim  of  mental  more  than 
physical  suffering  has  for  weeks,  or  even  months,  been  brooding  over  his 
complaint  during  all  his  waking  moments  not  absolutely  necessary  to  his 
daily  occupation,  exaggerating  each  trifling  symptom,  entertaining  the 
most  gloomy  forebodings  of  the  future,  and  perhaps  contemplating  suicide. 
First  of  all,  he  needs  a  friend  who  can  lead  him,  however  reluctantly^  to 
unburden  his  mind  of  its  sorrow.  This  load  removed,  he  at  once  feels 
lighter  and  more  hopeful.  The  surgeon's  first  object,  therefore,  should  be 
to  gain  his  confidence  by  friendly  yet  manly  conversation,  lending  a  ready 
ear  to  the  familiar  story  of  the  hypochondriac,  encouraging  him  to  feel 
that  he  has  found  a  sympathizing  friend  as  well  as  physician,  and  gradu- 
ally and  skilfully  leading  him  from  the  depths  of  despondency  to  more 
rational  views  of  his  position  and  prosi)ects  in  life. 

One  great  source  of  anxiety  to  the  patient  is  probably  the  idea  that  the 
transparent  viscid  discharge  which  appears  during  straining  at  stools,  or 
is  mingled  with  the  last  drops  of  urine,  consists  of  semen.  The  surgeon 
is  generally  safe  in  assuring  him  of  the  contrary,  without  special  examina- 
tion, since  diurnal  spermatorrhcca  without  some  degree  of  spasmodic  action 
is  exceedingly  rare  ;  but  any  doubt  upon  the  subject  may  be  removed  by 
placing  a  drop  of  the  fluid  under  the  microscope,  which  will  probably 
confirm  his  assurance  by  showing  the  absence  of  spermatozoa. 

Most  cases  of  chronic  prostatitis  require  the  administration  of  a  tonic, 

'  Coufiiderations  gcnerales  sur  la  pathogenic  des  maladies  de  la  prostate,  Paris, 
1874. 
2  These  de  Paris,  1860. 


TREATMENT.  177 

as  iron,  of  ■svliicli  the  tincture  of  the  chloride,  in  the  dose  of  twenty  drops 
after  each  meal,  is  one  of  the  best  preparations.  I  have  also  obtained 
favorable  results  from  a  solution  of  strychnia  in  dilute  phos[)horic  acid  : — 

^..    Strychnia  gr.  iss 0  10 

Acidi  Phospborici  Diluti  Jiv     .     .     .     125| 
Sig.  A  teaspoonful  three  times  a  day. 

Ergot,  either  alone  or  combined  with  camphor,  is  another  remedy  which 
may  often  be  employed  to  advantage.^ 

Chronic  inflammation  of  the  prostate  is  perpetuated  by  the  constipated 
state  of  the  bowels  and  consequent  straining  at  stool  which  usually  attends 
it,  and  which  should,  therefore,  be  obviated  by  laxatives  or  enemata ;  but 
aloes,  which  is  a  constituent  of  most  of  our  otficinal  preparations  for  this 
purpose,  should  be  avoided,  on  account  of  its  well  known  tendency  to 
produce  congestion  of  the  hemorrhoidal  vessels.  Saline  cathartics  may 
be  administered  in  small  doses  in  the  morning  on  rising ;  but  I  much  pre- 
fer enemata  of  cold  water,  taken  immediately  before  the  usual  time  of 
going  to  stool,  which  are  followed  by  a  loose  evacuation  unattended  by 
straining,  and  which  prevent  the  discharge  of  prostatic  fluid. 

Injections  of  a  few  drops  of  a  solution  of  nitrate  of  silver — one  to  five 
grains  to  the  ounce — into  the  prostatic  sinus,  by  means  of  a  deep  urethral 
syringe,  may  prove  serviceable.  It  is  probable  that  many  of  the  cures  of 
"  spermatorrhoea"  by  Lallemand  with  his  porte-caustique,  were  in  cases  of 
mere  prostatitis,  but  the  use  of  his  instrument  is  attended  with  no  little 
danger.  In  cases  complicated  with  gleet,  astringent  urethral  injections 
may  be  required.  The  presence  of  strictures  of  large  calibre  in  the  straight 
portion  of  the  canal  should  always  be  sought  for,  and  if  found  they  should 
be  cut.  Slitting  up  a  small  meatus,  as  recommended  by  Civiale  and  more 
recently  by  Dr.  Otis,  is  found  to  have  a  decided  influence  upon  aflfections 
at  or  near  the  neck  of  the  bladder,  jsartly  by  removing  an  obstruction  to 
the  free  exit  of  urine  and  partly  through  reflex  action. 

Blistering  the  perinseum  is  also  of  very  decided  benefit  in  these  cases. 
This  is  best  done  with  cantharidal  collodion,  which  is  to  be  painted  over 
a  small  surface  upon  either  side  of  the  raphe  ;  and  the  application  should 
be  repeated  over  another  spot  as  soon  as  the  soreness  of  the  first  has  begun 
to  subside. 

Moderate  sexual  indulgence  is  found  to  relieve  the  morbid  irritability  of 
the  genital  organs,  and  matrimony,  when  practicable,  should  be  recom- 
mended to  those  who  are  single. 

'  See  an  article  by  Dr.  C.  L.  Mitchell,  on  Ergot  in  Spermatorrhoea,  Congestion, 
and  Irritation  of  the  Genital  Organs  in  the  Male ;  Am.  M.  Monthly,  N.  Y.,  April, 
1861,  p.  283.' 


12 


178  INFLAMMATION    OF    THE    BLADDER. 


CHAPTER  XV. 

INF  LAMM  ATI  OX   OF   THE   BLADDER. 

Cystitis  is  another  complication  of  gonorrhoea,  occurring  as  a  conse- 
quence of  the  extension  of  the  inflammation  along  the  continuous  mucous 
surface  common  to  the  urethra  and  bladder.  It  has  also  been  attributed 
in  rare  instances  to  the  gonorrhoea!  discharge  finding  its  way,  or  being 
forced  into  the  bladder,  and  there  lighting  up  inflammation  similar  to  that 
affecting  the  urethral  walls.  A  case  of  this  kind  is  reported  in  the  Arch, 
gen.  de  mtd.,  Paris,  tome  xiii,  p.  454, 1829,  in  which  cystitis  suddenly  super- 
vened after  using  a  simple  emollient  injection.  All  those  causes  which 
aggravate  the  urethritis  may  concur  in  exciting  cystitis,  among  which  may 
be  mentioned  sexual  intercom se,  indulgence  in  alcoholic  stimulants  in- 
cluding malt  liquors,  fatigue,  and  the  use  of  highly  irritant  injections. 
Persons  who  have  suffered  from  hemorrhoids  or  hemorrhages  from  the 
rectum  are  especially  exposed  to  it.  Cystitis  never  occurs  at  the  com- 
mencement of  an  attack  of  gonorrhoea,  but  usually  after  the  third  week 
or  at  a  much  later  period,  when  the  disease  has  invaded  the  deeper  por- 
tions of  the  uretlira. 

Gonorrhoeal  cystitis  may  be  said  to  be  confined  to  the  neck  of  the  blad- 
der. Instances  of  the  whole  internal  surface  being  involved  are  denied 
bv  Fournier,  although  admitted  as  of  rare  occurrence  by  Zeissl  and  others. 

The  first  symptom  that  attracts  the  attention  of  patients  is  a  frequent 
call  to  micturate.  This  may  occur  every  hour  or  so,  or  even  every  five  or 
ten  minutes.  The  call,  too,  is  imperative,  and  if  unattended  to  at  once 
the  urine  will  be  passed  in  bed  or  within  the  pantaloons.  At  the  same 
time  there  is  a  feeling  of  uneasiness,  not  amounting  to  actual  pain,  in  tlie 
perinajum,  and  this  is  ap}iarent  chiefly  at  the  commencement  and  at  the 
close  of  micturition.  This  may  be  accompanied  by  a  tickling  or  itching 
sensation  at  the  head  of  the  penis.  The  first  portion  of  the  urine  that 
appears  on  urinating  is  often  clear,  but  the  last  few  droi)S  that  escape  are 
mixed  with  pus  and  more  or  less  blood,  or  a  few  drops  of  pure  blood  may 
alone  appear.  This  appearance  of  blood  at  the  close  of  the  act  is  a  valu- 
able diagnostic  sign  of  inflammation  of  the  neck  of  the  bladder. 

Another  valuable  diagnostic  sign,  experienced  at  the  same  moment — 
the  close  of  micturition — is  vesical  tenesmus  often  of  the  most  painful  and 
acute  character,  and  which  is  probably  due  to  spasmodic  contraction  of  tiie 
vesical  neck.  At  this  time,  in  severe  cases,  there  is  a  feeling  of  weight 
in  the  perina^um,  which  the  patient  endeavors  to  relieve  by  pressure  at 
that  point,  and  also  by  pinching  the  extremity  of  the  penis.     He  feels  as 


CYSTITIS.  179 

if  there  were  still  a  little  urine  left,  and  with  great  suffei'ing  manages  to 
force  out  a  few  drops  of  muco-pus  or  blood,  which  scald  the  urethra  in 
their  passage.  In  some  cases,  the  calls  to  urinate  are  so  frequent  as  to 
amount  to  incontinence,  and  the  patient  passes  a  few  drops  every  minute 
or  two.  As  ordinarily  met  Avith  in  practice,  however,  cystitis  of  the  neck 
is  much  milder  in  its  character,  and  amounts  simply  to  a  frequent  and 
imperative  desire  to  urinate,  accompanied  perhaps  with  a  small  amount  of 
tenesmus  and  the  admixture  of  pus  in  the  last  drops  passed. 

A  few  other  symptoms  of  gonorrha'al  cystitis  remain  to  be  mentioned. 
The  urine  is  acid  and  not  alkaline,  as  is  often  erroneously  stated.  It  be- 
comes alkaline  only  when  there  is  general  inflammation  of  the  bladder, 
and  then  in  consequence  of  its  fermentation  when  mixed  with  the  vesical 
pus  and  mucus.  Retention  of  urine,  which  we  have  seen  to  be  frequent 
in  prostatitis,  is  rare  in  cystitis.  In  many  cases  pressure  above  the  pubes 
is  not  at  all  painful ;  in  others  there  is  a  certain  amount  of  sensitiveness, 
the  difference  being  due,  as  is  supposed,  to  the  amount  of  urine  in  the 
bladder  causing  its  distention  or  not.  With  the  finger  in  the  rectum,  we 
find  the  prostate  of  normal  size,  but  firm  pressure,  which  is  communicated 
to  the  vesical  neck,  may  cause  some  uneasiness.  The  bowels  in  this  affec- 
tion are  habitually  constipated.  The  discharge  from  the  urethra  slackens 
or  holds  up  during  the  continuance  of  the  acute  symptoms,  but  returns  in 
full  force  as  these  subside. 

Unlike  prostatitis,  gonorrhoea!  cystitis,  except  in  severe  cases,  is  at- 
tended by  little  or  no  general  febrile  reaction,  but,  as  may  well  be  imag- 
ined, getting  out  of  bed  every  little  while  during  the  night  to  pass  water, 
the  consequent  loss  of  sleep,  the  repeated  attacks  of  pain  and  tenesmus, 
and  the  mental  anxiety  attending  it  all,  are  not  conducive  either  to  health 
or  ha[)piness,  and  patients  lose  their  appetite  and  flesh,  and  become  morose 
and  irritable. 

Fortunately  the  acute  symptoms  are  of  but  short  duration,  terminating 
perha[)S  in  three  or  four  days,  and  rarely  lasting  more  than  eight  to  twelve. 

It  has  been  questioned,  as  by  Founiier,  whether  the  whole  internal 
surface  of  the  bladder  ever  becomes  inflamed  in  consequence  of  the  ex- 
tension of  gonorrhocal  urethritis,  although  such  an  event,  and  even  inflam- 
mation of  the  ureters  and  kidneys,  has  been  reported.  Dr.  C.  Murchison 
relates  two  fatal  cases,  one  in  a  man  and  the  other  in  a  woman,  of  acute 
pyelitis  and  nejjliritis  ai)iiarently  consecjuent  on  gonorrhoea  (Trans.  Clinical 
Soc.  of  London,  vol.  ix,  187G,  p.  2.5). 

In  rare  instances  cystitis  of  the  neck  may  terminate  in  chronic  cystitis, 
but  the  latter  is  generally  due  to  other  causes,  as  stricture  of  tiie  urethra, 
hypertrophy  of  the  prostate,  the  presence  of  stone  or  morbid  growths  in 
the  bladder,  v^lisease  of  the  kidneys,  paralysis,  etc. 

The  diagnosis  between  prostatitis  and  cystitis  of  the  neck  of  the  bladder 
will  be  rendered  still  clearer  by  the  following  table,  which  is  borrowed 
from  Fournicr  : — 


180  INFLAMMATION    OF    THE    BLADDER. 

Cystitis  of  tue  Neck  of  tue  Bladder.  Prostatitis. 

I.  Cliaractoristic  i-es2ca/ tenesmus  ;  fre-  I.  Vesical  tenesmus  much  less.  Rec- 
quent  and  imperative  desire  to  urinate.      tal  tenesmus  more  marked. 

II.  Micturition  esijecially  painful  with         II.  Nothing  similar, 
the  passage  of  the  last  drojjs  of  urine, 

when  there  is  a  characteristic  convul- 
sive contraction. 

III.  Toward  the  close  of  micturition,  III.  Nothing  similar.  Urine  normal, 
excretion  of  a  thick  fluid,  a  mixture  of 

pus  and  hlood  ;  often  also  of  pure  blood. 

IV.  Mere  perineal  sensibility  ;  pains         IV.  Deep  perineal  pain,  very  acute, 
radiating  towards  the  anus  much  less     increased  by  motion,  defecation,  etc. 
violent  than  in  prostatitis. 

V.  Prostate  normal.  V.  A  very  sensitive,  hard,  prostatic 

tumor  is  felt  on  rectal  examination. 

VI.  No  retention  of  urine.  VI.  Dysuria.     Retention  of  urine. 

VII.  Few  or  no  general  symptoms.  VII.      General     symptoms     marked  ; 

fever,  loss  of  appetite,  etc. 

Treatment. — Rest  in  the  recumbent  posture  is  of  the  first  importance 
in  the  treatment  of  gonorrhoea!  cystitis,  and  it  is  well  to  place  a  pillow 
under  the  hips  so  as  to  elevate  the  pelvis  and  favor  the  return-flow  of  blood 
in  the  pelvic  vessels.  The  frequency  of  micturition  and  the  painful  spasms 
whicli  accompany  the  act  constitute  the  most  distressing  symptoms,  and 
these  may  often  be  greatly  relieved  by  the  introduction  of  pieces  of  ice  in 
the  rectum,  as  recommended  by  Horand."^  To  avoid  injury  to  the  rectal 
walls  from  the  sharp  edges  of  the  ice,  it  should  be  inclosed  in  a  thin  piece 
of  rubber  or  oil-silk,  or  better  still  a  condom,  and  the  latter  should  be  well 
greased.     The  application  sliould  be  renewed  every  hour  or  two. 

In  extreme  cases,  fortunately  rare,  the  abstraction  of  blood  from  the 
perinieum  by  means  of  cups  or  leeches  may  be  advisable.  This  region, 
however,  and  the  internal  surfaces  of  the  thighs  may  be  smeared  with  the 
extract  of  belladonna,  rubbed  up  with  glycerine.  Further  treatment  con- 
sists in  the  internal  administration  of  cold  mucilaginous  drinks,  with  the 
addition  of  the  nitrate  or  bicarbonate  of  potassa  and  the  fluid  extract  of 
hyoscyamus,  given  in  small  quantities  at  a  time.  Opium,  although  objec- 
tionable on  account  of  its  increasing  the  constipation,  must  often  be  given 
to  relieve  the  pain,  and  the  sulphate  or  acetate  of  morphia  [gramme  .Olo 
(ar.  ;^)],  with  the  exti-act  of  belladonna  [gramme  .01  (gr.  ^)J,  in  the  form 
of  suppository,  is  the  best. 

All  urethral  injections  must  be  stopped  and  no  attempt  be  made  to  intro- 
duce instruments  except  in  the  rare  cases  of  retention.  It  remains  to  allude 
to  a  few  other  modes  of  treatment  which  have  been  recommended.  Zeissl's 
favorite  mixture  for  internal  use  is  the  following : 

I^.    Ext.  Sem.  Hyoscyami, 

Ext.  Cannabis  Ind.,  ail  gr.  ij 0112 

Sacch.  alb.,  5J 4| 

M.  et  div.  in  ch.  no.  8.     One  to  be  taken  every  three  hours. 


I  Emploi  de  la  glace  centre  la  cystite  blenn.,  Lyon  m6d.,  t.  xv.,  1874,  p.  214. 


TREATMENT.  181 

The  use  of  the  Balsamics,  although  favorably  spoken  of  by  Hunter,  >A'as 
at  one  time  abandoned  and  indeed  tliought  to  be  injurious,  but  has  since 
been  recommended  by  Baizeau,^  RoUet,^  and  Fournier,^  The  last-named 
author  says  that  copaiba  sometimes  calms  the  erethism  of  the  vesical  neck 
in  a  marvellous  manner  in  a  few  hours,  but  adds  that  it  often  fails  completely. 
Sir  Henry  Thompson*  also  speaks  well  of  copaiba  in  some  cases  of  chronic 
inflammation  of  the  bladder,  but  says  that  the  doses  should  be  small,  as 
five  minims,  and  be  given  in  mucilage  three  or  four  times  a  day. 

In  place  of  the  ice  above  recommended  in  the  acute  stage,  some  authori- 
ties recommend  poultices  or  hot  fomentations  over  the  hypogastrium,  and 
hot  baths.  If  the  latter  be  employed,  immersion  of  the  whole  body  is  pre- 
ferable to  sitz-baths.  If  there  be  general  febrile  disturbance,  aconite  should 
be  given  internally. 

After  the  more  acute  symptoms  have  subsided,  benefit  will  be  derived 
from  the  internal  use  of  cantharides,  but  it  must  be  given  in  very  minute 
doses,  as,  for  instance,  one  drop  of  tlie  tincture  to  an  ounce  of  water,  of 
which  the  patient  is  to  take  a  teaspoonful  three  times  a  day.  Stronger 
doses  will  only  aggravate  the  trouble.  A  few  drops  of  a  tincture  of  chima- 
phila  umbellata,  administered  in  the  same  manner,  has  also  been  highly 
recommended. 

'  De  la  cystite  hem.  dii  col  complicaut  I'urethrite  et  de  son  traitement  par  les 
balsamiqiies.     Gaz.  d.  h8p.,  Paris,  1861,  p.  457. 

2  Traite  des  mal.  ven.,  Paris,  1861,  p.  314. 

3  Nouveau  diet,  de  med.  et  de  clii.  prat.,  t.  v,  p.  180. 

*  Diseases  of  the  Urinary  Organs,  3d  ed.,  1873,  p.  199. 


182  INFLAMMATION    OF    THE    VESICULyE    SEMINALES. 


CHAPTER   XVI. 

GONORRHCEAL    INFLAMMATION    OF    THE 
V  E  S  I  C  U  L  .E    S  E  Ikl  I  N  A  L  E  S  . 

GoNORRHCEAL  INFLAMMATION  of  tlie  seminal  vesicles  has  been  de- 
scribed by  several  authors,  as  Cruveilhier,  Andral,  Mercier,  Velpeau, 
Lallemand,  Gosselin,  and  Prof.  V.  Pitha,^  upon  whom  I  must  chiefly  rely 
for  its  description. 

It  is  unnecessary  to  dwell  upon  the  mode  of  its  occurrence,  since  this  is 
so  readily  explained  by  extension  of  the  inflammation  from  the  urethra 
through  the  ejaculatory  ducts.  It  may  also  be  caused  by  any  mechanical 
or  other  iri-itation  of  tlie  prostatic  portion  of  the  urethra.  The  symp- 
toms noticed  by  the  patient  are  much  the  same  as  those  of  prostatitis.  A 
constant  dull,  pressing  pain  is  felt  in  the  rectum,  shooting  from  the  neck 
of  the  bladder  to  the  sacrum.  This  pain  is  increased  by  the  passage  of  the 
feces,  especially  if  tliey  are  hard  ;  also  by  micturition,  by  erection  of  the 
penis,  and  above  all  by  any  attempt  at  coitus.  The  calls  to  defecation  and 
micturition  are  frequent,  and  the  latter  is  attended  with  dysuria.  Erec- 
tions of  the  penis  are  frequent  and  may  amount  to  constant  priapism. 
Involuntary  emissions  occur  from  time  to  time,  which  are  excruciatingly 
painful,  and  the  semen  is  found  to  be  reddened  with  blood  or  of  a  yellowish 
color  due  to  the  admixture  of  pus.  Even  between  the  emissions  a  slimy 
secretion  mixed  with  blood  and  pus  may  be  discharged  from  the  urethra, 
and,  under  the  microscope,  be  found  to  contain  spermatozoa. 

"Bloody  semen"  is  not  an  uncommon  occurrence  in  men  who  have  for 
some  time  suifered  with  a  chronic  gonorrhoea,  or  gleet.  They  usually  dis- 
cover it  by  the  stains  on  their  bedclothes  after  a  wet  dream,  or  by  the 
color  of  tlie  semen  in  a  condom  which  they  have  worn  iii  cottu,  and  they 
are  naturally  frightened  by  it.  It  does  not  always  indicate  that  the  vesi- 
cular seminales  are  involved,  but  shows  that  some  inflammation  still  re- 
mains in  the  prostatic  urethra  or  ejaculatory  ducts.  It  is  not  serious,  and 
often  disappears  spontaneously.  Its  appropriate  treatment,  if  any  be  re- 
quired, is  a  deep  urethral  injection  of  a  few  drops  of  a  solution  of  nitrate 
of  silver,  either  by  the  autlior's  deep  urethral  syringe  or  by  Guyon's 
method. 

Physical  examination  is  somewhat  diflicult;  but  with  a  long  finger  and 
some  adroitness  the  vesiculae  seminales  may  be  reached  through  the  rectum. 
They  lie  dii-ectly  above  the  prostate,  not  more  than  a  finger's  breadth  apart, 

'  Haii(ll)ucli  der  speciellen  Pathologie  und  Therapie,  redig.  von  Virchow,  6  Band, 
2  Abtheilung,  p.  132. 


INFLAMMATION    OF    THE    VESICUL^    SEMINALES.  1S3 

and  one  or  both  of  them  when  inflamed  may  be  felt  as  an  oval,  sensitive, 
hard  or  fluctuating  tumor,  which,  with  care,  need  not  be  mistaken  for  an 
abscess  of  the  prostate.     Pressure  upon  them  excites  a  dull  pain. 

In  some  cases,  this  affection  is  said  to  be  of  short  duration  and  to  leave 
no  traces  behind  it.  In  others,  the  cavity  of  the  vesicula  becomes  enlarged, 
even  to  twice  its  normal  size,  and  is  transformed  into  a  puriform  sac, 
which  may  either  break  in  the  perinieum,  giving  rise  to  infiltration  of  the 
neighboring  tissues  and  the  formntion  of  a  fistula,  or  it  may  empty  itself 
through  the  urethra.  Again  the  walls  of  the  vesicula  may  become  ulcer- 
ated and  the  sac  itself  obliterated,  in  which  case,  according  to  Gosselin, 
the  vas  deferens  and  even  the  epididymis  share  the  same  fate. 

When  the  acute  inflammation  terminates  in  a  chronic  form,  we  may 
have  thickening  and  induration  of  the  walls  of  the  sac,  with  chalky  deposits, 
or,  especially  in  scrofulous  subjects,  deposits  of  true  tubercle.  Usually  such 
tuberculosis  accompanies  a  general  affection  of  this  character,  but  occa- 
sionally it  is  limited  to  the  vesiculie  seminales,  or  at  least  to  the  urinary 
organs,  especially  the  kidneys,  in  addition  to  the  seminal  vesicles. 

Prof.  Y.  Pitha  reports  a  case  in  which  the  left  kidney  and  the  left  vesi- 
cula were  infiltrated  with  numerous  coarse  masses  of  tubercle,  partly  pulpy 
in  the  centre,  and  a  portion  of  the  prostate  gland  and  the  membranous 
part  of  the  urethra  were  the  seat  of  large  tuberculous  ulcers.  The  patient 
was  a  day-laborer,  aged  50. 

A'elpeau  observed  a  case  in  which  vesiculitis  terminated  in  an  abscess, 
followed  by  peritonitis  which  proved  fatal.     (Tarnowsky,  op.  cit.,  p.  330.) 

In  spite  of  tlie  nearness  to  each  oiher  of  the  two  openings  of  the  ejacu- 
latory  ducts,  both  vesiculie  are  rarely  attacked  at  the  same  time.  If  both 
are  involved,  resulting  in  such  changes  as  those  described,  impotency  must 
necessarily  folI<Jw. 

Inflammation  of  the  vesicular  seminales  can  rarely  be  diagnosticated 
with  absolute  certainty  during  life,  and  we  can  only  say  of  its  treatment 
that  symptoms  must  be  met  as  they  occur,  and  that,  in  general,  the  same 
remedies  are  applicable  as  in  prostatitis. 


184  GONORRHCEAL    PERITONITIS    IN    THE    MALE. 


CHAPTER    XVII. 

GOXOPtUHCEAL    PERITONITIS    AND    SUBPERI- 
TONEAL   ABSCESS    IN    THE    MALE. 

Only  a  few  cases  of  these  rare  conn)lications  of  gonorrhoea  have  ever 
been  reported,  and  I  am  indebted  for  the  material  of  this  chapter  to  the 
valuable  paper,  appearing  in  the  October  and  November  numbers  of  the 
Archives  generales  de  7nedecine,  1877,  by  Dr.  A.  Faucon,  who  reports  a 
case  of  subperitoneal  abscess  occupying  the  internal  portion  of  the  inter- 
nal iliac  fossa,  and  extending  upwards  four  fingers'  breadth  above  the  in- 
guinal cord. 

Instances  of  gonorrhoea!  peritonitis  had  before  been  reported  or  briefly 
referred  to  by  Hunter,'  Ricord,"  Gosselin,*  Dr.  Peter,*  and  Godard  ;*  one 
of  perinephritic  abscess,  by  Dr.  Laforgue,^  of  Toulouse,  all  of  them  origi- 
nating in  the  extension  of  the  inflammation,  first  from  the  urethra  to  its 
annexes,  and  second,'  from  the  latter  to  the  subperitoneal  cellular  tissue  or 
to  the  peritoneum  itself. 

Dr.  Faucon's  conclusions  at  the  close  of  his  paper  give  a  summary  of 
what  is  known  of  this  subject,  and  I  shall  cpiote  them  verbatim : — 

1.  Peritonitis  and  subperitoneal  abscess  should  be  ranked  among  the 
possible  complications  of  gonorrhoea. 

2.  These  accidents  are  only  distant  eflTccts  of  the  gonorrhoeal  inflamma- 
tion, extending  from  the  urethra  to  the  peritoneum  or  the  subperitoneal 
cellular  tissue  through  the  intervention  of  the  vas  deferens,  vesiculas  semi- 
nales,  the  prostate  (possibly  the  bladder,  ureters,  and  kidneys),  and  the 
cellular  tissue  surrounding  these  organs. 

3.  Their  appearance  is,  therefore,  always  preceded  by  the  more  ordi- 
nary complications  of  gonorrhoea,  resulting  from  the  preliminary  inflam- 
mation of  the  tissues  or  organs  which  serve  as  intermedia  (inflammation 
of  the  vas  deferens,  vesiculae  seminales,  etc.  etc.). 

4.  Gonorrhoeal  peritonitis  may  appear  at  diflfierent  points ;  thus  it  has 
been  seen  to  commence  in  the  pelvic  region  opposite  the  recto-vesical  cul- 
de-sac,  while  at  other  times  it  starts  from  the  internal  orifice  of  the  ingui- 
nal canal. 

5.  It  may  remain   localized  at   the   point   where  it  commenced,  and 

'  Ricord  and  Hunter  on  Venereal  (Bumstead's  translation,  2d  ed.),  p.  90. 
2  Ibid.,  p.  S)G. 

^  Clinique  cliirurgicale  de  I'hopital  de  la  Charlie,  Paris,  1873,  t.  II,  p.  3G4. 
<  Union  nied.,  Paris,  1856.  ^  Graz.  med.  de  Paris,  1856. 

6  Rev.  med  de  Toulouse,  Dec,  1876,  p.  355. 


GONORRH(EAL    PERITONITIS    IN    THE    MALE.  185 

terminate  favorably,  or  it  may  becoms  general  (or  at  least  extend  to  a 
more  or  less  considerable  portion  of  the  abdominal  cavity),  pass  into  a 
purulent  stage,  and  result  in  death. 

G.  The  gonorrhoeal  subperitoneal  abscess  has  been  observed  in  the  lum- 
bar fossa  and  at  the  lower  portion  of  the  internal  iliac  region,  and  of  the 
anterior  wall  of  the  abdomen.  It  may  terminate  by  resolution  or  by  sup- 
puration.    Its  influence  is  less  mischievous  than  that  of  peritonitis. 

7.  When  a  subperitoneal  abscess  has  formed,  it  should  be  opened  as 
soon  as  possible.  Decided  antiphlogistic  treatment,  the  prolonged  use  of 
ice  and  early  incision  may  arrest  its  development  and  prevent  its  passage 
into  suppuration. 


186  GONORRIKEA    IN    WOMEN. 


CHAPTER  XVIII. 

GONORRHCEA  IN    WOMEN. 

The  mucous  membrane  of  the  genital  organs  is  far  more  extensive  in 
the  female  than  in  the  male.  Besides  lining  tlie  urinary  canal  and  the 
vulva — parts  corresponding  to  the  urethra  and  balano-preputial  fold  in  man 
— it  is  continued  over  the  walls  of  the  vagina,  whei'e  its  surface  is  increased 
by  numerous  folds,  and,  reflected  over  tlie  os  tincoe,  extends  into  the  cavi- 
ties of  the  cervix  and  body  of  the  uterus.  Any  portion  of  this  extensive 
surface  may  be  attacked  by  catarrlial  inflammation,  which,  according  to 
its  seat,  is  called  gonorrlioea  of  the  vulva,  urethra,  vagina,  or  uterus. 
Some  of  these  parts  are  more  frequently  affected  than  others.  Thus,  gon- 
orrhoea of  the  vagina  is  more  commoia  than  that  of  the  urethra  or  vulva, 
and  gonorrhoea  of  the  uterus  is  the  least  frequent  of  all.  Zeissl  states  that, 
according  to  his  observations,  only  about  5  cases  of  uretliritis  are  met  with 
to  100  cases  of  vaginitis.  It  is  rare  for  all  the  different  portions  of  tlie 
female  genital  organs  to  be  attacked  together,  though  two  or  more  are,  in 
many  instances,  combined  as  the  seat  of  gonorrhceal  inflammation.  Tlie 
manner  of  union  appears  to  be  chiefly  determined  by  the  anatomical  rela- 
tion of  the  parts.  Thus,  when  the  vulva  is  afi^ected,  the  urethra  and  lower 
portion  of  the  vagina  are  likely  to  be  involved  ;  while  on  the  other  hand, 
the  upper  part  of  the  vagina  and  uterus  are  not  infrequently  implicated 
together. 

Causes Gonorrhoea  is  a  much  less  common  disease  in  women  than 

in  men.  This  may  be  accounted  for  by  several  reasons.  The  mucous 
membrane  of  the  vagina  is  less  sensitive  than  that  of  the  male  urethra ;  it 
receives  no  little  protection  from  the  sebaceous  and  mucous  secretions 
which  constantly  cover  it:  the  size  of  the  passage  is  such  that  it  can  be 
readily  cleansed ;  and  the  urethra,  in  consecpience  of  its  being  but  very 
slightly  concerned  in  the  sexual  act,  and  of  the  situation  of  its  meatus,  is  less 
exposed  to  contagion.  But  another  reason,  and  one  perhaps  of  still  greater 
weight,  is  to  be  found  in  the  absence  in  men  of  those  chronic  discharges  of 
simple  origin,  the  presence  of  which  in  women  is  so  fruitful  a  cause  of 
urethritis  in  the  opposite  sex.  When  speaking  of  the  causes  of  gonorrhoea 
in  the  male,  I  endeavored  to  show  that  it  is  frequently  due  to  the  irritation 
produced  by  a  leucorrhoeal  discharge,  by  the  menstrual  flow,  or  by  the 
normal  secretions  of  the  female  genital  organs.  Women,  in  sexual  inter- 
course, are  not  exposed  to  these  exciting  causes  of  gonorrhoea.  In  a  con- 
dition of  health,  there  is  no  secretion  about  the  male  genital  organs 
capable  of  exciting   inflammation  in   the  female ;  while  during   the   acute 


CAUSES.  18T 

sta^e  of  gonorrhoea  tlie  pain  excited  by  tiirgescence  of  the  penis  is  gene- 
rally sufficient  to  deter  from  coitus,  and  even  in  cases  of  gleet,  the  amount 
of  tlie  discharge  is  so  small,  the  urethra  so  frequently  cleansed  by  the  pas- 
sage of  urine,  and  the  vagina  so  well  protected  by  sebaceous  matter,  that 
intercourse  may  often  take  place  without  much  exposure  to  the  woman. 
Owing  to  these  circumstances,  w^omen  more  frequently  communicate  than 
receive  gonorrhoea. 

It  would  seem  to  be  a  fair  deduction  from  the  foregoing,  that,  taking  a 
given  number  of  gonorrhoeal  cases  in  the  two  sexes,  more  are  due  to  infec- 
tion in  women  than  in  men  ;  and  such  I  think  is  unquestionably  the  fact. 
But  wdiile  assigning  to  direct  contagion  the  first  place  in  the  etiology  of 
the  gonorrhcjea  of  w  omen,  other  influences  must  not  be  overlooked.  These, 
however,  are  less  appreciable  in  the  female  than  in  the  male.  The  history 
of  women  seeking  advice  for  gonorrhoea  can  rarely  be  ascertained  with 
certainty,  or  their  disease  traced  with  accuracy  to  its  source.  It  is  noto- 
rious that  a  woman  often  receives  the  embraces  of  several  men  within  a 
short  si)ace  of  time,  and  there  are  many  reasons  for  her  concealing  import- 
ant facts  which  a  man  would  readily  confide  to  his. physician.  It  is,  there- 
fore, only  under  peculiar  circumstances  that  we  can  satisfactorily  ascertain 
the  origin  of  gonorrhoea  in  women ;  still,  opportunities  for  such  investiga- 
tion do  sometimes  occur,  and,  in  several  which  I  have  met  with,  it  was 
evident  that  the  disease  was  due  to  other  causes  than  contagion.  Thus,  I 
have  known  intercourse  with  a  healthy  man  to  excite  acute  and  extensive 
inflammation  of  the  genital  organs  in  women  suffering  from  leucorrhoca  and 
congestion  of  the  cervix,  especially  if  the  stimulus  of  liquor  was  added  to 
that  of  coitus.  In  such  cases,  chronic  may  readily  be  transformed  into 
acute  inflammation  in  the  same  way  as  a  gleet  in  man  may  be  changed 
into  a  clap.  In  some  instances,  I  have  had  reason  to  believe  that  the 
frequent  repetition  of  the  sexual  act  has  produced  gonorrhoea  in  women 
free  from  any  previous  disease,  and  it  is  a  well  established  fact  that  a  pur- 
ulent discharge  sometimes  follows  the  first  exercise  of  marital  rights, 
although  there  may  have  been  no  laceration  of  the  female  genital  organs. 
The  use  of  pessaries  is  also  sometimes  the  cause  of  vaginitis,  which  has 
again  been  attributed  to  working  on  a  sewing  machine.  In  general,  the 
causes  of  gonorrhoea  in  women,  independ(;ntly  of  contagion,  may  be  enu- 
merated as  follows  :  Immoderate  sexual  intercourse,  violence,  masturba- 
tion, the  presence  of  vegetations,  syphilitic  or  other  eruptions,  errors  of 
diet,  ascarides  in  the  rectum,  and  the  external  influences  of  cold,  moisture, 
etc. 

Certain  conditions  of  the  constitution  at  large,  as  chlorosis  and  scrofula, 
play  an  important  part  in  the  causation  or  maintenance  (when  first  ex- 
cited by  oilier  causes)  of  gonorrhoea  in  women,  far  more  so,  indeed,  than 
they  do  in  men. 

Many  women  have,  during  pregnancy,  a  muco-pnrulent  discharge,  which 
usually  makes  its  appearance  after  the  fourth  or  fifth  month,  though  some- 
times before,  and  chiefly  affects  the  upper  portion  of  the  vagina.  An  ex- 
amination of  the  vaginal  mucous  membrane  reveals  the  existence  of  nume- 


188  GONORRIICEA    IN    WOMEN. 

rous  granulations,  similar  to  those  observed  also  in  some  cases  of  vaginitis 
from  contagion.  Cazeaux  states  tliat  this  discharge  may  produce  disorder 
of  the  digestive  functions,  as  shown  by  the  coexistence  of  gastralgia,  which 
is  more  or  less  severe  according  to  the  intensity  of  the  vaginitis.^  The 
discharge  usually  disappears  spontaneously  after  the  termination  of  ges- 
tation. 

Vaginitis  may  be  attendant  u])on  scarlet  fever,  or  it  may  follow  this  and 
the  other  exanthemata  as  a  sequela.^ 

Very  young  girls  may  be  attacked  with  inflammation  of  the  genital  organs, 
producing  a  copious  purulent  discharge  from  the  vulva,  and  sometimes  from 
the  vagina  also,  the  cause  of  which  has  often  been  misapprehended.  It 
has  been  supposed  that  the  disease  was  contracted  from  men  who  had  been 
seen  to  caress  or  fondle  them,  and  innocent  persons  have  been  arrested  and 
tried  on  this  charge.  No  one  in  such  cases  has  done  more  for  the  honor 
of  our  profession  and  for  the  cause  of  humanity  than  the  late  Mr.  Wilde,  of 
Dublin,  who  repeatedly  came  forward  when  the  accused  party  was  about  to 
be  convicted  for  an  offence  which  he  never  committed,  showed  the  ground- 
lessness of  the  charge  and  proved  his  innocence.  In  most  cases  the  dis- 
charges in  question  are  no  more  venereal  in  their  nature  than  the  otorrhcea 
which  is  so  common  in  children.  Their  predisposing  cause  is  genei-al  ca- 
chexia, or,  as  it  is  commonly  called,  a  strumous  diathesis.  The  exciting 
cause  may  be  deficient  cleanliness,  derangement  of  the  digestive  functions, 
the  irritation  of  teething,  and  the  presence  of  ascarides  in  the  rectum,  or 
within  the  vulva,  where  they  may  have  found  their  way  from  the  gut. 
Such  discharges  are  contagious  when  applied  to  the  ocular  conjunctiva, 
and  not  less  so,  in  all  probability,  if  brought  in  contact  with  the  genital 
organs  of  a  second  person  ;  thereby  proving  that  the  contagiousness  ,of 
gonorrhocal  matter  depends  upon  the  seat  of  the  disease,  and  not  upon  the 
presence  of  a  specific  poison  necessarily  transmitted  from  one  individual 
to  another. 

Symptoms The  initiatory  symptoms  of  gonorrhoea  in  women  are  often 

obscured,  in  the  rare  instances  afforded  for  their  examination,  by  the  pre- 
vious existence  of  a  leucorrhoeal  discharge.  They  do  not  differ  from  the 
early  symptoms  of  inflamrqation  of  other  mucous  membranes,  and  consist 
in  the  gradual  development  of  swelling,  redness  and  tenderness,  and  an 
increase  of,  and  change  in,  the  secretion  of  the  part.  The  discharge  varies 
in  consistency  and  color  as  in  gonorrhoea  in  the  male.  It  is  at  first  trans- 
parent and  mucous,  then  muco-purulent,  and  finally,  when  the  disease  has 
attained  its  height,  thoroughly  purulent.  When  secreted  by  the  vagina,  it 
is  acid,  fluent,  creamy,  and  readily  removed  from  the  surface  ;  when  de- 
rived from  the  cavity  of  the  cervix,^  without  being  mixed  with  the  acid 

'  Traite  de  I'art  des  accouchemeiits,  4e  Edition,  p.  317. 

2  CoRMACK,  London  Journal  of  Medicuie,  Sept.  1850,  p.  872;  and  Barnes,  Medi- 
cal Gazette,  July  12,  1850,  p.  65. 

3  The  most  convenient  method  of  collecting  the  cervical  secretion  for  the  pur- 
pose of  examination,  unmixed  with  the  vaginal  mucus,  is  by  means  of  Lallemand's 
porte-caustique,  uncharged. 


GONORRHCEA    OF    THE    VULVA.  189 

matter  of  the  vagina,  it  is  alkaline,  nearly  transparent,  tenacious  like  the 
white  of  egg,  and  very  adhesive.  Examined  under  the  microscope,  the 
vaginal  secretion  is  found  to  consist  of  pus-corpuscles,  mucus,  an  abund- 
ance of  epithelial  scales  and  flakes  of  epithelium  in  masses ;  while  the 
viscid  plug  drawn  from  the  cervix,  which,  as  shown  by  Dr.  Tyler  Smith, 
is  glandular  in  its  structure,  exhibits  mucus-corpuscles,  oil-globules,  and 
purulent  matter.  The  consistency  and  yellowish  color  of  the  vaginal  se- 
cretion are  dependent  upon  the  quantity  of  organized  elements  it  contains. 
The  thicker  it  is,  the  more  opaque,  and  the  more  resemblance  it  bears  to 
cream  or  pus,  the  greater  the  quantity  of  pavement  epithelium  and  pus- 
globules,  as  shown  by  the  microscope.^ 

M.  Donne  has  also  called  attention  to  the  presence  of  a  small  infusorial 
animalcule  which  he  at  first  supposed  to  be  pathognomonic  of  gonorrhoeal 
vaginitis.  He  has  since  renounced  this  opinion,  but  still  asserts  that  the 
Trichomonas  is  not  seen  in  healthy  vaginal  mucus,  but  only  where  there 
is  a  large  admixture  of  pus-globules.  Farther  researches  by  Kolliker  and 
Scanzoni^  would  show  that  it  is  never  present  in  the  secretion  of  the  cervix, 
so  that  it  cannot  be  a  mere  cell  of  ciliary  epithelium,  and  these  authors 
state  that  there  can  be  no  doubt  of  its  independent  animal  nature.  It  was 
first  found  by  them  in  pregnant  women,  and,  after  their  attention  was 
called  to  it,  in  more  than  half  the  women  whom  they  examined.  Hence 
it  cannot  be  considered  as  characteristic  of  gonorrhoea.  Still,  it  is  never 
met  with  in  perfectly  healthy  mucus,  destitute  of  pus-globules.  It  appears 
to  depend  upon  certain  changes  in  the  vaginal  secretion,  and  is  not  devel- 
oped to  any  extent  except  in  mucus  which  is  clearly  abnormal.^ 

Traces  of  a  discharge  from  the  genital  organs  are  to  be  sought  for  chiefly 
upon  the  posterior  portion  of  a  woman's  linen,  and  not  upon  the  anterior. 
The  absence  of  any  external  evidence  of  disease  does  not,  however,  prove 
her  sound,  since  the  upper  portion  of  the  vagina  may  be  inflamed  and  the 
secretion  be  retained  within  the  vulva.  The  symptoms  of  gonorrhoea  in 
women  vary  according  to  the  part  affected,  and  it  is  convenient  to  make 
a  corresponding  division  in  their  description,  recollecting,  at  the  same 
time,  that  the  different  forms  may  be  more  or  less  combined  in  a  given 
case. 

Gonorrhoea  of  the  vulva  is  less  common  than  that  of  the  vagina,  and, 
in  many  cases,  is  secondary  to  the  latter,  being  produced  by  contact  with 
the  discharge  flowing  from  above.  It  is,  howevei-,  often  primary,  and  is 
that  form  which  is  commonly  met  with  as  the  result  of  violence,  or  the 
presence  of  vegetations  and  syphilitic  or  other  eruptions,  as  venereal  ulcers, 
mucous  [latches,  etc.  The  gonorrhoea  of  young  girls,  already  referred  to, 
is  also,  in  most  cases,  vulvar. 

The  parent's  attention  is  early  attracted  to  the  part  by  a  sensation  of 

'  Pathology  and  Treatment  of  Leucorrhcea,  Phil,  ed.,  1855,  p.  122. 

2  Das  Secret  d.  Schleimhaut  d.  Vagina  und  des  Cervix  Uteri.  Scanzoni's  Bei- 
triige,  Bd.  ii,  p.  128.     Wurzburg,  1855. 

3  Traitc  pratique  des  maladies  des  organes  sexuellea  de  la  femme,  par  F.  W. 
DE  ScANZoxi ;  traduit  de  TAUemaud,  Paris,  1858,  p.  452. 


190  GONORRHCEA    IN    "WOMEN. 

heat  and  pruritus.  On  examination,  tlie  mucous  membrane  is  found  to  be 
reddened,  tumefied,  and  more  moist  tlian  natural.  As  the  disease  ad- 
vances the  discharge  inci'eases  in  quantity  and  becomes  muco-purulent,  or 
purulent,  and  very  oiFensive.  The  labia  and  nymphte  may  be  swollen  to 
such  a  degree  as  to  render  it  almost  impossible  to  expose  the  orifice  ot"  the 
vagina.  If  the  nymj)ha3  be  naturally  large,  they  may  swell  to  such  an 
extent  as  to  protrude  beyond  the  labia  and  become  constricted;  a  condition 
which  may  be  compared  to  paraphimosis.  The  mucous  membrane  may 
be  deprived  of  its  epithelium  in  patches,  identical  in  character  with  the 
superficial  excoriations  of  balanitis.  The  inflamed  parts  are  exceedingly 
sensitive  to  the  slightest  touch  or  pressure,  and  motion  is  very  painful. 
The  last  drops  of  urine  fall  upon  the  excoriated  surface  and  give  rise  to 
severe  scalding.  The  discharge  collects  in  the  hair  on  the  mons  veneris 
and  upon  the  external  surface  of  the  labia,  and  flows  upon  the  integument 
of  the  perinamm,  and  upon  the  upper  portions  of  the  thighs.  Wherever 
it  remains  for  any  length  of  time  it  irritates  and  inflames  the  skin,  which 
soon  assumes  an  erythematous  or  even  excoriated  condition,  and  itself 
secretes  an  acrid  humor.  If  the  discharge  comes  in  contact  with  the  anus, 
as  is  very  likely  to  occur  when  the  patient  lies  upon  the  back,  it  may  pro- 
duce iri'itation  of  the  rectum,  attended  with  frequent  desire  to  go  to  stool, 
pain  on  the  passage  of  the  feces,  and  sometimes  slight  diarrhoea.^ 

The  sexual  desires  are  often  heightened,  and  amount  at  times  to  nym- 
phomania, but  coitus  is  attended  Avith  severe  pain,  if  it  even  be  possible. 
No  other  form  of  gonorrhoea  in  women  equals  this  in  the  sufi'ering  which 
it  occasions.  This  is  partly  owing  to  circumstances  already  mentioned, 
and  partly  also  to  the  great  sensibility  jjossessed  by  the  vulva  in  common 
with  other  outlets  of  mucous  canals.  The  general  system  sometimes  sym- 
pathizes with  the  local  disease,  and  the  patient  is  found  to  be  hot  and 
feverish.  All  cases  of  vulvar  gonorrhoea  are  not,  however,  so  severe  as 
that  just  described.  Instances  occur  in  which  there  is  but  little  redness, 
tumefaction,  or  sensibility,  and  merely  an  increase  of  the  mucous  secretion 
of  the  part ;  and  the  symptoms  may  vary  all  the  way  from  this  mild  char- 
acter to  the  intensity  of  tiie  above  description. 

The  anatomy  and  pathology  of  the  glandular  apparatus  of  the  female 
genital  organs  have  been  admirably  given  by  M.  Huguier.^  The  vulva  is 
abundantly  supplied  with  sebaceous  and  muciparous  follicles,  which  are 
lined  by  a  ])rolongation  of  the  mucous  membrane.  Travelling  along  this 
continuous  surface  the  inflammation  readily  gains  access  to  the  interior  of 
the  follicles,  which  soon  pour  out  a  thick  purulent  secretion  from  their 
mouths.  The  follicles  project  from  the  surface  of  the  mucous  membrane, 
in  the  form  of  numerous  small  prominences  with  ulcerated  tips  from  which 
the  matter  escapes.  This  is  the  "  sebaceous  or  follicular  vulvitis,"  so  called 
by  Frencli  authors. 

The  entrance  to  the  vagina  is  also  i)rovided  with  two  larger  and  more 

'  Baum^s,  Precis  sur  les  maladies  ven^riennes,  t.  11,  p.  163. 
2  Memolres  de  TAcad^mie  de  uicd.,  1850,  p.  529. 


GONORRHOEA    OF    THE    VULVA 


191 


deeply  situated  seci'etory  organs,  whicli,  although  noticed  by  several  anato- 
mists subsequent  to  the  seventeenth  century,  were  comparatively  unknown 
up  to  quite  a  recent  date.  These  glands  were  first  discovered  by  Duverney 
in  the  cow,  and  afterwards  by  Bartholin  in  women,  but,  having  been  sought 


Fig.  43. 


Sebaceous  vulvitis.    (Huguier.) 

for  in  vain  by  Haller,  they  were  entirely  forgotten,  until  attention  was 
again  called  to  them,  in  1840,  by  TiedmannJ  of  Heidelberg,  and  by  M. 
Huguier,  of  Paris,  in  1850.  They  are  now  known  by  the  name  of  Duver- 
ney's,  Bartholin's,  Cowper's,  or  the  vulvo-vaginal  glands.  In  a  few  rare 
cases  they  are  said  to  be  wanting.  They  are  situated,  one  on  either  side 
of  the  entrance  to  the  vagina,  in  the  triangular  space,  bounded  by  the 
ascending  ramus  of  the  ischium,  the  vaginal  orifice,  and  the  transversalis 
perinaii  muscle,  and  are  covered  by  the  superficial  perineal  fascia,  and 
some  fibres  of  the  constrictor  vagina:.  Tiieir  size  varies  in  different  sub- 
jects, and  they  appear  to  be  largest  in  women  addicted  to  sexual  inter- 
course. "When  most  developed  their  diameter  usually  measures  about  six- 
tentlis  of  an  inch.  They  are  conglomerate  glands,  consisting  of  congeries 
of  small  tubes,  surrounded  by  a  common  envelope,  and  during  the  act  of 
coitus,  pour  out  a  copious  secretion  of  albuminous  fluid,  by  means  of  a 
duct  six  or  seven  lines  in  length,  opening  just  in  front  of  the  hymen,  or 
near  the  lateral  and  posterior  caruncula;  myrtiformes,  which  often  conceal 
the  orifice. 


'  Von  den  Duverneysclien  Diiisen  ;  Heidelberg,  1840. 


192 


GONORRHCEA    IN    WOMEN. 


Fis,  44. 


Tlie  inflammatory  process  may  invade  tliis  duct  and  the  gland  beyond 
it,  in  the  same  manner  that  it  does  the  superficial  follicles;  and  when  sup- 
puration has  taken  place,  if  the  matter  do  not  find  free  exit  through  the 
natural  outlet  of  the  gland,  an  abscess  is  formed  either  within  the  dilated 
duct,  or  in  the  substance  of  the  gland  itself;  the  former  being  generally 
the  case  when  gonorrhoea  is  the  exciting  cause.  The  copious  cellular  tissue 
of  the  labium  major  surrounding  the  gland  may  also  take  on  inflammation 
and  an  abscess  form  both  within  and  without  the  gland,  as  we  see  occur 
in  inflammatory  buboes  in  the  groin. 

A  frequent  and  peculiar  feature  of  abscesses  of  this  gland,  is  the  facility 
wuth  which,  having  once  emptied  themselves,  they  again  till  up  on  the  oc- 
currence of  any  slight  cause,  as  a  return  of  the  menstrual  pei'iod,  indul- 
gence in  sexual  intercourse,  exacerbation  of  the  vulvar  inflammation,  etc. 
This  circumstance  has  led  some  authors  to  the  erroneous  conclusion  that 
these  abscesses  are  surrounded  by  a  true  cystic  wall,  whereas  their  envelope 
continues  to  be,  as  at  first,  either  the  dilated  duct  or  gland,  which,  to  a 
certain  extent,  performs  the  office  of  a  cyst.  These  glandular  abscesses, 
however,  may  generally  be  recognized  without  much  difficulty.  The  patient 
complains  of  a  "  swelling"  in  the  vicinity  of  the  vulva,  which,  on  exami- 
nation, is  found  to  occupy  the  lower  third 
of  the  labium,  and  borders  upon  the  pos- 
terior commissure.  The  affected  side  is 
more  prominent  than  its  opposite,  and  the 
labium  is  pear-shaped,  with  its  broader 
extremity  directed  backwards  and  in- 
wards towards  the  median  line  ;  the 
integument  on  its  external  aspect  are- 
serves  its  normal  color,  and  is  i'ree  and 
movable,  Avhile  the  internal  surface  of 
mucous  membrane  is  red  and  adherent 
to  the  tumor.  The  part  is  exceedingly 
sensitive  to  the  touch,  and  the  patient 
can  neither  walk,  stand,  nor  sit,  without 
difficulty,  owing  to  the  pain  excited  by 
the  slightest  pressure.  The  contents  of 
the  tumor  are  occasionally  discharged 
through  the  normal  duct  of  the  gland, 
but  usually,  unless  art  intervene,  the 
abscess  bursts  in  the  neighborhood  of  the 
glandular  orifice,  and  very  rarely  on  the 
external  or  integumental  surface  of  the 
labium.  M.  Huguier  contradicts  the 
statement  made  by  Vidal  and  other  authors,  that  a  recto-vaginal  fistula  is 
liable  to  form.  This  never  occurs,  according  to  the  first  named  surgeon, 
if  the  rectum  be  in  a  sound  condition.  The  frequent  recurrence  of  abscesses 
of  the  vulvo- vaginal  gland,  or  duct,  is  a  source  of  great  annoyance  to  women 
of  the  town,  when  suffering  from  chronic  inflammation  of  the  vulva. 


Inflammation  of  the  vulvo-vaginal  gland. 


VAGINITIS.  193 

Inflammation  of  Bartholin's  gland  may  be  caused  by  onanism  in  women 
who  have  never  been  entered,  and  also  by  syphilitic  lesions  in  the  neigh- 
borliood,  although  it  is  generally  due  to  extension  of  the  inflammation  of 
vaginitis  or  vulvitis. 

Dr.  Salmon'  has  called  attention  to  certain  cases  of  gonorrhoea,  in  which 
the  vulvo-vaginal  gland  and  duct  are  alone  aflTected,  the  remainder  of  the 
genito-urinary  organs  retaining  their  normal  condition.  According  to  this 
surgeon,  the  affection  is  quite  common,  and  especially  so  among  young 
prostitutes,  in  whom  it  would  seem  to  be  due  to  the  irritation  of  coitus  upon 
parts  as  yet  tender.  The  patient  experiences  no  pain  or  inconvenience, 
and  an  examination,  such  as  is  ordinarily  made,  might  lead  to  the  conclusion 
that  the  genital  organs  were  sound  ;  but  if  the  labium,  on  one  or  both  sides, 
be  firmly  pressed  against  the  ramus  of  the  ischium,  the  gland,  which  is  not 
perceptible  to  the  touch  in  a  state  of  health,  may  be  felt  as  a  moderately 
firm  tumor,  and  its  muco-puriform  contents  escape  from  the  orifice  of  the 
duct. 

Some  women  of  the  town  are  said  to  learn  the  trick  of  performing  this 
little  manoeuvre  before  being  examined  by  a  surgeon  so  as  to  conceal  their 
disease.  This  may  also  explain  some  instances  in  which  two  men  have 
connection  with  the  same  woman  in  rapid  succession,  and  the  first  catches 
a  clap  but  the  second  escapes.  The  first,  by  his  pressure,  evacuates  the 
abscess  and  pays  the  penalty,  while  the  other  goes  free  (Zeissl).  Dr. 
Salmon  expresses  the  opinion  that  many  cases  of  gonorrhoea  in  the  male, 
following  intercourse  with  women  apparently  healthy,  are  due  simply  to 
the  puriform  secretion  furnished  by  this  gland.  Dr.  Le  Pileur  has  reported 
a  very  interesting  and  carefully  observed  case,  in  which  a  physician  con- 
tracted a  severe  clap  from  a  woman  in  whom  no  disease  could  be  found 
except  an  abscess  of  the  vulvo-vaginal  gland.- 

Vaginitis  is  more  common  than  any  other  form  of  gonorrhoea  in  women. 
The  whole  extent  or  only  a  portion  of  this  passage  may  be  inflamed.  The 
lower  part  is  more  or  less  implicated  in  most  cases  of  vulvitis,  while  fre- 
quently the  upper  part  is  alone  involved,  and  the  woman  might  be  supposed 
free  from  disease  if  not  examined  with  the  speculum;  especially  as,  from 
the  comparative  insensibility  of  the  upper  portion  of  the  vagina,  her  sen- 
sations are  an  unreliable  index  of  its  condition.  Ricord  states  that  the 
posterior  wall  of  the  vagina  is  more  frequently  affected  in  leucorrhcea,  and 
the  anterior  wall  in  gonorrhoea. 

The  modern  application  of  the  speculum  to  the  study  of  venereal  dis- 
eases (for  which  we  are  indebted  to  Ricord)  has  rendered  an  affection, 
which  was  before  obscure  and  of  difficult  diagnosis,  at  once  clear  and  easily 
recognizable,  and  the  zeal,  of  late  years,  brought  to  the  patliologieal  in- 
vestigation of  the  female  genital  organs,  has  induced  many  observers  to 
describe  the  lesions  of  vaginitis  with  srreat  minuteness  and  detail.    It  is  not 


'    Mod.  Timt'S  and  Gaz.,  Dec.  23,  1854,  \^.  (j4tJ,  quoted  from  Union  m^dicale. — 
Braithwaitfi's  Retros])ect,  part  31,  p.  208. 

^  Ann.  de  Derm,  et  Syph.,  Paris,  t.  9,  1878,  no.  5,  p.  374. 
13 


194  GONORRHCEA    IN    WOMEN. 

to  be  regretted  that  these  lesions  have  been  subjected  to  so  severe  a  scrutiny, 
although  they  have  for  this  reason  acquired  an  unmerited  degree  of  import- 
ance, since  it  has  been  shown  that  they  are  characterized  by  no  features 
sufficiently  peculiar  to  indicate  their  venereal  origin,  and  that  they  are,  in 
nearly  all  respects,  identical  with  the  more  familiar  morbid  appearances  of 
other  mucous  membranes,  as  the  conjunctiva  oculi,  the  lining  membrane 
of  the  mouth,  ear,  etc. 

The  speculum  should  not  be  employed  during  the  acute  stage  of  vagi- 
nitis, as  it  is  likely  to  excite  severe  pain  and  irritate  the  inflamed  tissues. 
The  presence  of  the  catamenia  is  also  a  contraindication  to  its  use. 
The  ordinary  cylindrical  instrument,  made  of  glass  and  coated  with  a 
layer  of  India  rubber,  is  of  easy  introduction,  and  is  generally  sufficient 
for  the  examination  of  the  vagina  in  suspected  cases  of  gonorrhoea,  but 
when  it  is  desired  to  make  local  applications,  or  when  thorough  exposure 
of  all  the  recesses  of  this  passage  is  requisite  in  order  to  discover  if  any 
concealed  chancre,  or  chancroid,  be  present,  either  a  valvular  or  Sims's 
speculum  should  be  preferred.  In  order  to  remove  the  discharge  which 
may  obstruct  the  field  of  vision,  the  surgeon  should  provide  himself  with 
several  swabs,  which  may  be  conveniently  made  by  winding  cotton  wadding 
around  the  end  of  a  thin  splinter  of  wood. 

When  the  vaginitis  is  intense  and  seen  at  an  early  period,  a  portion  or 
the  whole  of  the  vaginal  walls  may  be  found  red,  hot,  and  dry,  and  entirely 
destitute  of  moisture.  Ricord  states  that  in  several  instances  he  has  seen 
this  condition  finally  terminate  in  resolution  without  the  slightest  discharge 
appearing  at  any  time.  Similar  cases  of  dry  or  erysipelatous  gonorrho-a 
have  been  reported  as  occurring  in  men,  although  the  difficulty  of  examin- 
ing the  internal  surface  of  the  urethra  throughout  its  whole  extent  has.left 
them  open  to  criticism.  Generally,  however,  this  dry  condition  of  the 
vagina,  if  present  at  the  outset,  is  succeeded  in  the  course  of  twenty -four 
hours  by  the  iippearance  of  a  discharge,  which,  at  first  transparent,  after- 
wards undergoes  changes  similar  to  tliose  which  occur  in  gonorrhci'a  in  the 
male;  and  when  the  disease  has  attained  its  lieight,  the  vaginal  walls  are 
bathed  with  offisnsive,  purulent  matter  of  a  creamy  or  greenish  color,  or 
sometimes  streaked  with  blood.  As  already  stated,  this  discharge  is  acid, 
whereas  the  secretion  from  all  other  inflamed  mucous  membranes  of  the 
body  is  alkaline.  Zeissl  endeavors  to  explain  this  by  saying  that  the  se- 
cretion from  the  vagina  and  vulva  is  not  identical  with  that  from  the 
mucous  follicles  of  the  cervix  uteri  in  women  and  the  urethra  in  men,  but, 
to  ray  mind,  this  seems  to  be  only  carrying  the  difliculty  one  remove 
further  off.  Before  proceeding  with  the  examination,  the  field  of  tiie  spe- 
culum must  be  cleared  from  the  discharge  by  the  assistance  of  the  swabs 
of  cotton-wadding,  when  the  mucous  membrane  will  be  exposed.  This 
surface  is  found  to  be  red  and  tumefied.  The  redness  varies  in  intensity 
and  also  in  extent.  It  is  sometimes  uniform,  and  at  others  arranged  in 
spots  or  striae.  Frequently  patches  are  seen  from  which  the  epithelium 
has  become  detached,  forming  superficial  abrasions  similar  to  those  met 
with  in  balanitis,  or  resembling   blistered  surfaces.     Another  condition 


VAGINITIS.  195 

Avhich  is  at  times  met  with  has  received  the  name  of  granular  vaginitis. 
It  consirJts  in  a  development  of  the  vaginal  papillae,  which  project  above  the 
surrounding  surface,  and  are  readily  recognized  by  their  darker  red  color. 
It  may  also  be  due  to  the  enlargement  of  follicles,  as  is  evident  from 
the  pus  oozing  out  of  them  as  the  edge  of  the  speculum  passes  over  them. 
These  granulations  are  most  frequently  observed  in  the  upper  part  of  the 
vagina,  where  they  may  exist  in  large  numbers  covering  the  whole  sur- 
face, or  they  may  be  merely  scattered  here  and  there.  Tliey  have  been 
erroneously  regarded  by  Dr.  Deville  as  peculiar  to  the  vaginitis  of  preg- 
nant women. ^  They  are  analogous  to  the  granulations  which  are  so  com- 
mon upon  the  ])alpebral  conjunctiva.  Ricord  says  tliat,  in  one  case  of 
vaginal  gonorrhoea,  he  observed  an  eruption  presenting  every  appearance 
of  herpes  phlyctenodes  situated  upon  the  deeper  portion  of  the  vagina, 
and  Ashwell  speaks  of  "herpetic  pustules,"  which  by  bursting  form  ulcers. 

In  addition  to  the  above  symptoms,  vaginitis  is  characterized  by  in- 
creased heat  and  sensibility.  The  former  may  be  verified  by  introducing 
a  finger  within  the  vagina,  when  the  parts  will  be  felt  to  be  much  hotter 
than  natural.  The  degree  of  sensibility  varies,  and  is  greatest  when  the 
vulva  is  also  involved.  In  such  cases,  it  is  generally  quite  impossible  to 
introduce  a  speculum,  owing  to  the  pain  which  it  excites ;  but  when  the 
disease  is  confined  to  the  vagina,  this  instrument  may  often  be  employed 
without  causing  much  suffering.  During  the  course  of  vaginitis,  there  is 
often  a  frequent  desire  to  pass  the  urine,  and  dull  pain  is  felt  in  the  hypo- 
gastric region,  owing  to  sympathy  excited  on  the  part  of  the  bladder. 

Gonorrhoea  of  the  vagina  rarely  continues  any  length  of  time  without 
extending  to  the  mucous  membrane  covering  the  cervix,  which  may  ex- 
hibit lesions  identical  with  those  now  described,  but  more  especially 
patches  of  superficial  erosion.  Gonorrhoea  of  the  uterus  is  commonly 
confined  to  the  cavity  of  the  cervix.  It  is  usually  secondary  in  this  situa- 
tion, being  occasioned  by  the  extension  of  the  disease  from  the  vagina, 
and  very  rarely  primary.  The  lijjs  of  the  os  are  seen  to  be  tumefied  and 
red,  the  cervix  congested  and  enlarged,  and  its  cavity  filled  with  tenacious 
and  transparent  muco-purulent  matter.  This  secretion  owes  its  trans- 
parency to  the  alkali  which  it  contains.  It  becomes  curdled  and  opaque 
when  mixed  with  tlie  vaginal  acid,  and  hence  cannot  always  be  recognized 
after  it  has  descended  into  the  vagina  or  is  discharged  from  the  vulva. 
The  fact  that  gonorrhoea  confined  to  the  cervix  uteri  may  readily  be  over- 
looked, may  explain  some  of  the  cases  in  which  a  clap  is  derived  from  an 
apparently  healthy  womaTi. 

The  acute  stage  of  vaginitis  rarely  continues  longer  than  a  week  or  ten 
days,  and  may  be  of  much  shorter  duration.  As  the  acute  symptoms  sub- 
side, the  pain  and  difficulty  of  motion  are  diminished.  The  discharge 
becomes  less  copious  and  j)urulent,  and  the  redness  and  tumefaction  of  the 
tissues  gradually  disappear.  After  this  partial  advance  towards  recovery, 
however,  the  disease  often  lingers  for  an  indefinite  period,  and  is  extremely 

'  Arch.  G6n.  de  M4d.,  Paris,  4e  serie,  vol.  v,  p.  305. 


196  GONORRH(EA    IN    WOMEN. 

difficult  to  eradicate.  The  vaginal  walls  may  seem  to  have  recovered 
their  normal  condition,  having  lost  the  morbid  appearances  which  charac- 
terized tlie  acute  stage,  but  there  is  still  a  small  amount  of  discharge  from 
their  surface  or  from  the  cervical  cavity,  which  is  capable  of  producing 
gonorrhoea  in  the  male. 

Tlie  occurrence  of  menstruation  is  ahvays  a  set-back  in  cases  of  vagi- 
nitis, both  on  account  of  its  interrupting  treatment  and  the  congestion  of 
the  parts  during  this  period.  If  a  woman  was  supposed  to  be  well  or 
nearly  well  at  the  time  her  courses  came  on,  she  should  always  be  ex- 
amined again  after  they  have  ceased.  Tlie  persistence  of  this  disease  in 
a  subacute  chronic  form  is  almost  always  due  to  those  constitutional  causes 
already  mentioned  M'hen  speaking  of  its  etiology.  In  consequence  of  its 
long  duration  the  vaginal  walls  may  lose  their  soft  velvet-like  feel,  and 
become  coarse,  rough,  and  dry. 

Dr.  Tilt^  says  that  vaginitis,  even  when  not  very  severe,  may  be  fol- 
lowed by  such  an  amount  of  contraction,  that  it  becomes  necessary  to 
notch  the  unyielding  ring  to  focilitate  labor.  "  The  occlusion  has  been 
known  to  be  complete  through  the  whole  length  of  the  canal."  He  quotes 
Dr.  DanieP  as  saying  that  in  one  West  African  tribe,  a  young  woman 
who  permits  illicit  connection  is  handed  over  to  the  matrons  of  the  com- 
munity, who  stuff  her  vagina  with  a  pulp  made  of  the  unripe  pods  of  cap- 
sicum, and  thus  produce  a  super-acute  vaginitis,  which  is  followed  by  so 
contracted  a  state  of  the  vagina,  that  intromission  is  ever  after  prevented. 

Gonorrhcea  of  the  uterus The  cervix  uteri  is  often  involved  by  ex- 
tension of  gonorrha>al  inflammation  from  the  vagina.  It  may  also  be  pri- 
marily attacked,  as  is  readily  explained  by  the  fact  that  this  is  the  part  of 
the  female  genital  organs  against  which  the  glans  penis  most  impinges  in 
the  sexual  act,  and  consequently  the  part  where,  in  chronic  gonorrhoea 
especially,  a  drop  of  contagious  matter  issuing  from  the  meatus  of  the 
male,  is  very  likely  to  be  alone  deposited.  I  have  seen  repeated  instances 
in  which  the  mucous  membrane  covering  the  cervix  and  the  upper  part  of 
the  vagina  was  the  seat  of  acute  inflammation,  while  the  lower  and  outer 
portions  of  the  genitals  were  intact. 

On  examination  with  the  speculum,  we  find  the  usual  symptoms  of  in- 
flammation of  a  mucous  membrane,  congestion,  redness,  varying  in 
intensity,  development  of  the  papillae,  and  at. first  a  thin  and  afterwards 
a  purulent  discharge.  As  the  acute  inflammation  subsides,  we  often  see 
superficial  ulcerations  of  the  cervix,  seated  especially  upon  the  posterior 
lip.  When  the  muciparous  follicles  are  involved,  they  appear  in  the  form 
of  granulations,  varying  in  size  from  a  millet-seed  to  a  pea,  and  capable 
either  of  undergoing  resolution  or  of  breaking  of  the  follicular  abscesses, 
leaving  behind  small,  roundish  ulcerations.  Since  the  cervix  is  almost 
devoid  of  sensibility,  gonorrhoea  confined  to  this  part  occasions  but  little 
pain,  but  may  give  rise  to  general  malaise,  reflex  neuralgias,  disturbance 
of  digestion,  and  irregularity  in  menstruation. 

'  Uterine  Therapeutics,  4th  ed.,  1878,  p.  353. 

^  Native  Diseases  of  the  Gulf  of  India,  London,  1849. 


GONORRHOEA    OF    THE    URETHRA.  19T 

Gonorrliocal  infllaniniation  may  also  involve  the  cavity  of  the  cervix,  in 
which  case  we  find  a  peculiar  gelatinous  secretion,  resembling  in  appear- 
ance the  white  of  an  egg,  projecting  from  the  os,  and  so  tenacious  that  it 
is  with  difficulty  removed  even  by  a  swab.  It  is  sometimes  detached 
spontaneously  in  lumps,  falling  into  the  vagina,  where  it  excites  no  little 
irritation,  and  is  finally  discharged  through  the  vulva  upon  the  patient's 
linen.  The  alkaline  reaction  of  this  secretion  in  contrast  to  the  acidity 
of  the  vaginal  discharge  has  already  been  mentioned. 

In  describing  this  secretion,  we  should  not  fail  to  observe  that  it  is  by 
no  means  to  be  considered  as  characteristic  of  gonorrhceal  contagion,  since 
it  may  depend  upon  many  other  affections  incident  to  women.  A  proba- 
bility of  its  gonorrhceal  origin  would  be  afforded  by  the  fact  that  it  had 
been  preceded  by  acute  vaginitis,  or  that  it  had  coexisted  for  a  consider- 
able time  witii  chronic,  subacute  inflammation  of  the  upper  portion  of  the 
vagina.  Here,  as  in  urethral  discharges  from  the  male,  an  accurate  diag- 
nosis is  often  impossible,  for  the  simple  reason  that  there  is  nothing  specific 
in  the  disease. 

This  discharge  from  the  os  uteri  is  often  innocuous,  especially  in  married 
life  and  in  persons  of  cleanly  habits,  but  under  the  (usually)  oft-repeated 
intercourse  between  the  unmarried  or  when  attention  to  cleanliness  is  not 
observed,  it  is  liable  to  occasion  gonorrhoea  in  the  male. 

Still  further  upwards  may  the  inflammation  of  gonorrhoea  extend,  in- 
volving the  lining  membrane  of  the  cavity  of  the  uterus  itself.  We  do 
not  propose  to  enter  fully  into  the  category  of  symptoms  which  may  be 
thus  produced,  and  which  belong  rather  to  the  domain  of  gynaecology.  We 
will  merely  enumerate  some  of  them,  as  various  disturbances  of  menstrua- 
tion and  especially  an  irregular  and  profuse  monthly  flow;  gradual  dilata- 
tion of  the  uterine  cavity  from  the  collection  and  decomposition  of  the 
secretion  from  its  walls,  and  hence  so-called  physometra;  abnormal  flexions 
of  the  uterus;  and,  finally,  the  disturbances  of  the  digestion  and  general 
health  of  the  patient  which  these  conditions  are  sure  sooner  or  later  to 
entail  (Zeissl). 

Gonorrhoea  of  the  urethra  usually  coexists  with  that  of  the  vulva,  or 
vagina,  and  sometimes  with  that  of  the  uterus  alone.  Cases,  however,  are 
reported  in  which  this  was  the  only  part  of  the  genital  organs  aftected. 
Gibert  met  with  three  such  instances,^  Kicord  with  two,^  and  Cullerier 
with  one  ;^  and  in  several  of  them,  it  was  noticed  that  the  stains  of  the 
discharge  upon  the  woman's  linen  were  small  and  circular,  instead  of  being 
large  and  irregular  as  in  cases  of  vulvar  and  vaginal  gonorrhoea. 

The  shortness  of  the  urethra  in  women  and  the  oblique  position  of  the 
canal,  which  favors  the  spontaneous  flow  of  matter,  renchn*  tiie  diagnosis 
of  the  urethritis  less  easy  than  in  the  male.     The  discharge  in   cases  of 

'  Gibert's  first  caso  was  published  in  th«  Rev.  med.,  Paris,  t.  i,  1834.  He  has 
also  (riven  two  other  cases  in  his  Manuel  sur  les  maladies  sypliilitiques,  p.  284. 

2  Mem.  Acad.  roy.  de  med.,  t.  2e,  p.  l.'JO,  Paris,  1833. 

3  N.  Diet,  de  m6d.  et  de  cliir.  prat.,  Paris,  t.  4e,  p.  253. 


198  GONORRHCEA    IN    WOMEN. 

vulvitis,  also,  being  seen,  as  might  easily  happen,  in  the  vicinity  of  the 
meatus,  may  be  erroneously  supposed  to  come  from  that  orifice.  Again, 
tiie  passage  of  urine  causes  all  traces  of  ui-ethritis  to  disappear  for  a  time. 
An  examination,  in  order  to  be  conclusive,  should  be  made  at  least  an  hour 
or  two  after  an  evacuation  of  the  bladder,  and  any  discharge  around  the 
meatus  should  first  be  removed.  The  finger  may  then  be  passed  into  the 
vagina,  and  pressure  be  made  against  the  pubic  arch,  in  the  course  of  the 
canal,  from  behind  forwards ;  when,  if  urethritis  be  present,  one  or  more 
drops  of  purulent  matter  will  appear  at  the  meatus,  the  lips  of  which  will 
be  found  swollen  and  inflamed ;  and  the  introduction  of  a  sound  into  the 
canal  is  attended  with  considerable  pain.  Scalding  during  micturition 
may  easily  be  a  deceptive  symptom,  since  it  may  be  produced  to  a  still 
greater  degree  by  the  contact  of  the  urine  with  the  excoriated  nuicous 
membrane  of  the  vulva,  when  the  latter  is  involved.  If  no  vulvitis  be 
present,  it  is  a  symptom  of  value.  A  few  drops  of  blood  are  sometimes 
mixed  with  the  discharge,  but  hemorrhages  are  never  soco))ious  as  in  ure- 
thritis in  the  male.  Gonorrhoea  of  the  urethra,  occurring  in  women  other- 
wise healthy,  does  not  show  the  same  tendency  to  run  into  a  gleet  as  in  men. 
It  almost  always  disappears  before  the  accom[)anying  vaginitis  or  vulvitis, 
and  is  tlierefore  to  be  regarded  as  of  secondary  importance.*  In  broken- 
down  constitutions,  however,  and  in  women  who  have  borne  many  chil- 
dren, or  who  are  suffering  from  congestion  of  the  abdominal  viscera,  it  may 
assume  a  chronic  form,  and  prove  exceedingly  obstinate.  A  thickening 
takes  place  throughout  the  whole  canal,  which  can  be  traced  as  a  firm  cord 
behind  the  })ubes,  and  may  be  seen  standing  out  in  relief  at  the  upper  part 
of  the  entrance  of  the  vulva,  when  the  nymi)hi>3  are  separated.  This  con- 
dition is  attended  with  uncomfortable  sensations  in  the  part,  and  a  frequent 
desire  to  pass  water,  aggravated  by  motion,  by  coitus,  and  the  return  of 
the  menstrual  period,  and  relieved  by  rest  and  the  recumbent  posture.^ 

The  shortness  of  the  urethra  in  women  also  favors  the  extension  of  the 
inflammation  to  the  neck  of  the  bladder,  in  which  case  the  dysuria  is  very 
distressing. 

Vegetations  often  spring  up  around  the  meatus,  partially  or  almost 
wholly  closing  the  orifice,  and  interfering  with  the  i)assage  of  the  urin3. 

The  value  of  urethritis  as  indicating  contagion  has  been  noticed  by  many 
authors.  In  the  majority  of  cases  in  which  it  is  present,  patients  acknow- 
ledge that  they  have  been  exposed  to  impure  intercourse.  Eveiy  physi- 
cian knows  how  common  it  is  for  the  vulva  and  vagina  to  become  inflamed 
from  causes  other  than  contagion,  but  he  will  find  it  difficult  to  recall  a 
single  case  of  like  character,  in  which  the  urethra  was  inflamed  and  gave 
forth  a  purulent  secretion ;  hence  purulent  urethritis  in  women  is  strong 
presumptive  proof  of  contagion. 

1  DuKAND  Fardkl,  Memoiro  sur  la  blennorhagie  chez  la  feinrno,  et  ses  rlivorses 
complications.     J.  d.  conn,  nied.-cliir.,  Paris,  juillet,  aout,  et  Septembre,  1840. 

2  West,  Lectures  on  the  Diseases  of  Women,  2d  ed.  p.  (jl8. 


COMPLICATIONS.  199 

Complications Bubo  is  a  less  frequent  complication  of  gonorrhaa  in 

women  than  in  men,  and  Ricord  states  that  it  very  rarely  occurs  unless 
the  urethra  is  affected.^  Durand  Fardel  reports  the  case  of  a  woman  who 
had  a  rape  committed  upon  her  by  several  men,  and  in  whom  a  bubo 
formed  and  terminated  in  suppuration.^  An  examination  showed  that  she 
had  acute  inflammation  of  the  vulva  and  vagina,  and  that  there  was  no 
laceration  or  ulceration  of  the  mucous  membrane,  yet  the  violent  origin  of 
the  disease  would  excite  suspicion  as  to  the  bubo  being  due  entirely  to  the 
gonorrhoea.     No  mention  is  made  of  the  condition  of  the  urethra. 

Vegetations,  mucous  patches  or  tubercles,  chancroids  and  chancres,  are 
frequently  found  to  coexist  with  gonorrhoea  of  different  portions  of  the 
female  genital  organs,  and  especially  with  vulvitis.  Their  presence  is  a 
constant  source  of  irritation,  and  their  removal  is  essential  to  a  cure  of  the 
primary  disease.  Vegetations  should  be  destroyed  by  the  knife  or  caus- 
tics ;  mucous  patches  are  a  symptom  of  syphilis,  and  require  general  as 
well  as  local  treatment ;  and  chancres  and  chancroids  are  to  be  treated 
according  to  rules  to  be  laid  down  hei'eafter. 

Inflammation  of  the  Fallopian  tubes  sometimes  occurs  as  a  consequence 
of  the  extension  of  the  disease  from  the  uterine  cavity.  At  the  post- 
mortem examination  of  a  case  of  this  character,  M.  Mercier^  found  one 
tube  obliterated  by  a  deposit  of  lymph  upon  its  fimbriated  extremity,  and 
the  peritoneal  surface  inflamed  to  a  considerable  extent  around  it.  In  a 
case  reported  by  Bernutz  and  Goupil,  small  abscesses  were  found  upon  the 
walls  of  the  tubes  on  one  side,  while  on  the  other  side  there  was  a  puru- 
lent collection  within  the  peritoneal  cavity,  possibly  due  to  the  passage  of 
matter  from  the  tube.  The  obstruction  and  obliteration  of  the  Fallopian 
tubes  in  this  manner  will  doubtless  account  for  the  well-known  barrenness 
of  prostitutes  in  some  cases. 

Ovaritis  has  been  mentioned  by  a  number  of  authors  as  another  com- 
plication ;  among  others  by  Ricord,*  who  considers  it  analogous  to  gonor- 
rhoea! epididymitis  in  the  male.  Ricord  describes  his  case  as  follows  : 
TJie  patient,  aged  thirty-two,  an  inmate  of  the  Hopital  da  Midi,  was 
suffering  from  acute  gonorrhoea  of  the  uterus  and  external  genital  organs, 
when  a  swelling  suddenly  appeared  in  the  left  iliac  fossa.  The  part  was 
very  sensitive  to  the  touch  and  its  temperature  increased.  Tliere  was 
considerable  febrile  excitement  and  nausea.  The  patient  lay  on  her  back, 
inclined  a  little  to  the  left,  with  the  thighs  flexed.  The  discharge  from 
the  urethra  and  vagina  had  almost  entirely  disappeared.  Pressure  upon 
the  neck  of  the  uterus,  with  the  finger  introduced  within  the  vagina,  was 
not  painful ;  but  when  the  womb  was  pressed  toward  the  right  side,  pain 
and  a  sense  of  tension  were  felt  in  the  left  broad  ligament.  Pressure 
toward  the  left  side,  tried  for  the  sake  of  comparison,  caused  scarcely  any 

'  Not<'S  to  Hunter,  BurasteacL's  translation,  2d  ed.,  Phil.,  1850,  p.  107. 

2  Op.  cit. 

3  Meinoire  sur  la  peritoiiite  consitlereo  commo  cause  de  sterility  cliez  les  femmes, 
Gaz.  Tiicil.  de  I'aris,  1838,  p.  577  ;  also  Gaz.  de  hop.,  Paris,  1846,  p.  43li. 

*  Notes  to  Hunter,  2d  ed.,  p.  lOU. 


200  GONORRIICEA    IN    WOMEN. 

inconvenience.  The  passage  of  the  feces  and  urine,  and  all  motion  of  the 
abdominal  walls  were  painful.  Under  the  use  of  antiphlogistic  remedies, 
these  symptoms  gradually  diminished  and  disappeared  in  about  twelve 
days,  and  at  the  same  time  the  discharge  increased  in  quantity.  The 
patient,  however,  was  shortly  afterwards  seized  with  a  second  attack  on 
the  opposite  side,  with  the  same  sym[)toms  and  the  same  suspension  of  the 
discharge.' 

The  late  Mr.  De  ]\Ieric  also  reported  three  cases  of  gonorrhocal  ovaritis 
in  the  London  Lancet,  June  14,  1862,  which  were  followed  by  two  cases, 
by  Mr.  John  Taylor,  in  the  same  journal  for  July  12,  18G2. 

It  is  doubtful,  however,  whether  the  ovaries  can  be  affected  in  the  same 
isolated  manner  as  the  epididymis  in  man.  Their  inflammation  in  these 
cases  is  probably  part  and  parcel  of  the  gonorrhocal  pelvi-peritonitis 
already  alluded  to,  and  which  was  first  thoroughly  studied  in  the  admira- 
ble work  of  Bernutz  and  Goupil.^  These  authors  observed  this  affection 
at  Lourcine  Hospital,  in  Paris,  in  an  extraordinary  proportion  of  cases, 
since  out  of  ninety-three  women  who  entered  with  gonorrhcea,  twenty- 
eight  had  pelvi-peritonitis,  or  nearly  one  in  three  !  This  proportion  can- 
not, of  course,  be  taken  as  the  general  rule,  for  it  was  doubtless  the 
occurrence  of  this  severe  complication  which  led  many  of  them  to  come  to 
the  hospital,  while  hundreds  of  uncomi)licated  cases  of  gonorrhcea  stayed 
away. 

In  the  cases  seen  by  Bernutz  and  Goupil  there  was  no  instance  of  the 
occurrence  of  the  peritoneal  affection  before  the  eighth  day.  It  was  rare 
before  the  fourteenth,  but  frequent  towards  the  end  of  a  month,  that  is, 
about  at  the  menstrual  period.  De  Meric,  on  the  contrary,  states  that  in 
his  cases  the  ovary  became  affected  at  the  most  acute  point  of  the  disease. 
The  immediate  causes  may  be  regarded  as  the  recurrence  of  the  menses, 
fatigue,  and  excessive  sexual  indulgence.  There  follows  an  almost  com- 
plete cessation  of  the  vaginal  discharge.  For  the  symptoms  I  must  refer 
the  reader  to  works  on  the  diseases  of  women,  as  gonorrhoeal  pelvi-perito- 
nitis does  not  differ  from  that  due  to  other  causes. 

Diagnosis Before  the  application  of  the  speculum  to  the  study  of 

venereal  diseases,  the  diagnosis  of  gonorrlujea  in  women  was  often  difficult 
and  sometimes  impossible  ;  and  the  discharges  of  vaginitis  and  of  various 
syphilitic  lesions  within  the  vulva  were  confounded  together.  To  a  sur- 
geon of  the  present  day,  acquainted  with  modern  methods  of  investigation, 
such  mistakes  are  not  likely  to  occur.  With  the  recognition  of  the  dis- 
ease, however,  our  power,  so  far  as  diagnosis  is  concerned,  ceases.  It  is 
impossible  to  go  farther  and  determine  its  origin.  Many  authors  have 
attempted  to  give  diagnostic  signs  Jis  between  gonorrhoea  originating  in 
contagion  and  that  produced  by  other  causes,  but  they  have  all  most  sig- 
nally failed  to  produce  any  which  are  at  all  satisfactory,  simply  for  the 

1  Notes  to  Hunter,  p.  107. 

2  Clinique  med.  sur  les  mal.  d.  femmes,  Paris,  1862,  t.  ii,  p.  140. 


TREATMENT.  201 

reason  that  none  such  exist.  "  The  microscope  fails  to  furnish  us  with  a 
means  of  distinguishing  between  gonorrhoeal  and  simple  vaginitis,  and  no 
symptom  or  combination  of  symptoms  is  absolutely  conclusive  on  this 
point.'"  Acute  inflammation  and  the  presence  of  urethritis  may  render 
impure  intercourse  probable,  but  cannot  be  regarded  as  decisive  ;  and  what 
is  wanting  in  the  physical  diagnosis  must  be  sought  for  in  the  history  of 
the  case. 

Treatment. — The  treatment  of  the  different  forms  of  gonorrhoea  in 
women  varies  but  little  in  the  acute  stage  of  the  disease.  It  is  chiefly 
during  the  chronic  stage  that  any  variation  is  required  to  meet  special  in- 
dications, presented  by  inflammation  of  particular  portions  of  the  mucous 
membrane.  Moreover,  nature  does  not  always,  nor  indeed  in  most  in- 
stances, follow  the  classification  which  we  have  found  it  convenient  to 
adopt ;  several  of  the  genito-urinary  organs  are  generally  involved  together 
• — more  commonly  the  vagina  and  vulva — and  the  treatment  of  this  most 
numerous  class  of  cases  will  first  claim  our  attention. 

The  chief  remedies  adapted  to  the  acute  stage  are  rest,  cathartics,  hot 
baths,  lotions,  and  a  general  antiphlogistic  regimen.  Zeissl  recommends 
cold  applications  over  the  genitals,  which  should  be  changed  as  soon  as 
they  become  warm.  It  is  of  the  first  importance  that  the  patient  should 
abstain  from  exercise  of  all  kinds,  and,  if  possible,  be  confined  to  her 
bed;  indeed,  in  most  cases  her  own  sensations  demand  this,  without  the 
order  of  the  surgeon.  Meats  and  stimulants  should  be  forbidden,  and  the 
diet  restricted  to  weak  tea,  toast,  a  decoction  of  flaxseed,  rice-  or  barley- 
water,  gruel,  etc.,  unless  the  symptoms  are  subacute  from  the  first,  or  the 
patient  debilitated.  In  selecting  a  cathartic  at  the  outset  of  the  disease, 
preference  should  be  given  to  a  mercurial,  for  the  purpose  of  unloading 
the  abdominal  and  pelvic  vessels,  and  the  bowels  should  afterwards  be 
freely  opened  every  day,  by  small  doses  of  Epsom  salts,  citrate  of  mag- 
nesia, and  other  salines.  Aloes,  and  the  numerous  preparations  which 
contain  it,  should  be  avoided,  on  account  of  its  tendency  to  produce  con- 
gestion of  the  ha^morrhoidal  vessels. 

Blood-letting Bleeding  from    the  arm   and   even   the  application   of 

leeches  in  the  neighborhood  of  the  genital  organs,  may  be  said  to  be 
things  of  the  past  ;  although  the  latter  may  possibly  be  required  in  rare 
instances.  If  used,  they  should  be  applied  to  the  groins,  where  their 
bites  will  not  be  smeared  with  the  discharge. 

Baths  and  Lotions A  hot  bath,  repeated  once  or  twice  a  day  during 

the  acute  stage,  is  very  grateful  to  the  feelings  of  the  patient,  and  bene- 
ficial in  equalizing  the  circulation  and  relieving  the  local  inflammation  ; 
and  immersion  of  the  whole  body  is  to  be  preferred  to  hip-baths. 

Meanwhile,  the  external  genital  organs  should  be  frequently  bathed 
with  some  emollient  lotion,  and  a  piece  of  lint  soaked  in  the  same  be  in- 
sei'ted  between  the  labia,  in  order  to  separate  the  inflamed  surfaces  and 

'  West,  op.  cit.,  p.  628. 


202  GOXORRHffiA    IN    WOMEN. 

absorb  the   discharge.     The   following  is   an    excellent    formula   for   this 

purpose : — 

R.     Dt'cocti  Papavoris  3  pts. 

Liqiioiis  Plumbi  Siibacetat.  dilut.  1  pt. 
M. 

Diday  recommends   the   introduction   at   night   of  pledgets   of   cotton, 
smeared  with  the  followins;  ointment : — 


I^.     Cucumber  Ointment  §j 30 

Alum  3j 4 

Tannin  J^ij 2 

M. 


60 


These  should  be  removed  in  the  morning,  and  the  following  wash  be 
applied  or  injected  : — 

^..     Decoction  of  White  Oak  Bark  Oj     .     .  5001 

Borax  §ss 15| 

M. 

Sedatives,  of  which  Dover's  powder  is  perhaps  the  best,  should  be  ad- 
ministered at  night  to  induce  sleep,  and  also  at  intervals  during  the  day, 
if  the  pain  is  severe,  or  the  patient  nervous  and  irritable. 

Injections The  above  measures  are  the  only  ones  admissible  during 

the  acute  stage  of  the  disease,  especially  if  the  vulva  is  involved  ;  in  which 
case  the  insertion  of  an  enema  tube  is  too  painful  to  admit  of  injections. 
When,  however,  the  inflammation  is  chiefly  confined  to  the  vagina,  the 
lotion  just  mentioned  may  be  injected  into  this  canal  every  few  hours, 
and  in  many  cases  of  a  subacute  type,  injections  may  be  used  from  the 
very  commencement.  As  soon  as  the  sensibility  of  the  parts  will  permit, 
it  is  also  desirable  to  introduce  a  speculum,  and  ascertain  if  any  ulcer  be 
present. 

The  kind  of  syringe  used,  and  the  mode  of  injecting,  are  matters  of  no 
little  importance.  The  small  metallic  or  glass  instruments  in  common 
use  are  entirely  inadequate  for  the  removal  of  the  discharge.  The  as- 
tringent ingredients  of  the  first  portion  of  fluid  injected  are  spent  in 
coagulating  the  purulent  matter  collected  in  the  vagina.  To  wash  away 
the  coagula  thus  formed,  and  exert  a  medicinal  effect  upon  the  mucous 
membrane,  the  quantity  of  the  injection  should  not  be  less  than  a  pint ; 
indeed,  it  is  better  to  precede  any  medicated  injection  by  a  copious  one  of 
plain  water,  so  as  to  cleanse  the  vaginal  walls  as  freely  as  possible.  A 
pump-syringe,  or  better  still,  one  of  Davidson's  or  Mattson's  syringes, 
made  of  India  rubber,  and  provided  with  metallic  valves,  will  enable  the 
patient  to  inject  any  desired  quantity  with  one  introduction  of  the  tube. 
"While  using  the  injection,  the  patient  should  lie  on  her  back,  with  the 
pelvis  elevated ;  if  she  merely  stoop  down,  the  fluid  escapes  as  fast  as  it  is 
injected,  and  fails  to  reach  the  deeper  portions  of  the  canal.  With  a  bed- 
y)an  under  her  the  wetting  of  the  floor  and  clothes  will  be  avoided. 
Farther,  I  must  not  forget  to  mention  the  excellent  vaginal  douche,  de- 
picted below,  the  invention  of  Dr.  Frank  P.  Foster,  of  this  city. 

The  well-known  "  fountain  syringe"  may  also  be  employed. 


TREATMENT. 


203 


As  a  general  rule,  injections  of  greater  strength  may  be  used  for  women 
than  for  men,  and  for  the  sake  of  cheapness  and  convenience,  they  are 
commonly  made  more  simple  in  their  composition.  The  patient  may  be 
supplied  with  the  solid  ingredients,  and   allowed  to  mix  them  as  required, 


Fig.  45. 


Foster's  vaginal  douche 

and  in  order  to  avoid  the  expense  of  having  them  put  up  by  the  druggist 
in  divided  portions  ready  for  use,  it  is  desirable,  among  the  ])Oor,  to  supply 
tliem  in  bulk.  A  little  instruction  from  the  surgeon  will  enable  the  patient 
to  measure  them  out  with  sufficient  accuracy.  A  heaping  teaspoonful,  or, 
in  other  words,  as  much  as  can  possibly  be  taken  up  by  a  teas[)Oon,  of  the 
more  common  ingredients  of  injections,  is  nearly  as  follows  : — 

Almii  5'.i        ^ 

Sul2)liat(!  of  zinc  5'j 8 

Acetate  of  zinc  5'*^^ 6 

Subacetate  of  h;ad  3iij 12 

Tannin  5ss 2 

From  one  to  two  drachms  of  either  of  these  salts  to  the  pint  of  water, 
is  th<i  average  strengtii  employed,  but  the  ratio  should  always  be  pro- 
j)ortioned  to  the  effi.'Ct  produced,  and  the  sensibility  of  the  parts.  When- 
ever severe  or  long-continued  pain  is  induced,  the  strength  of  the  solution 
should  be  at  once  diminished,  and  afterwards  increased  as  the  tenderness 


204  GONORRIKEA    IN    WOMEN. 

becomes  less.  I  would  I'epeut  wliat  I  have  said  with  reference  to  injec- 
tions for  men,  that  young  [)ractitioners  often  h)se  time,  to  the  neglect  of 
more  important  matters,  in  frecjuently  changing  from  one  form  to  another  ; 
cases,  however,  occur,  in  which  one  injection  aj)pears  to  lose  its  effect, 
and  another  may  be  substituted  with  advantage,  but  no  change  should  be 
made,  unless  it  is  evident  that  the  unsatisfactory  result  is  not  due  to  a 
faulty  method  of  using  the  syringe,  or  to  constitutional  causes,  or  again, 
unless  the  solution,  however  diluted,  excites  pain  and  uneasiness. 

Wiien  the  subsidence  of  the  more  acute  symptoms  first  permits  the  in- 
troduction of  an  enema-tube,  a  drachm  of  alum  may  be  dissolved  in  a 
pint  of  flaxseed  tea,  and  injected  warm,  but  the  temperature  should  be 
gradually  lowered,  and  the  injection  ultimately  used  cold.  Injections  of 
cold  water  alone,  during  the  chronic  stage  of  vaginitis,  are  of  great  value. 
Tiiey  not  only  cleanse  the  parts,  but  exert  a  tonic  influence  upon  the 
vagina  and  neighboring  organs.  Their  effect,  however,  is  increased  by 
the  addition  of  alum,  or  the  other  salts  above  mentioned.  They  should 
be  employed  from  two  to  three  times  a  day,  but  must  be  omitted,  for  ob- 
vious reasons,  during  tlie  menstrual  periods. 

A  combination  of  tannin  and  alum,  as  recommended  by  Dr.  Tyler 
Smith, ^  is  also  an  excellent  form  of  injection,  and  one  which  I  have  pre- 
scribed with  much  success.  The  proportions  are  5*^-1  of  tannin,  and  3ij 
of  alum  to  the  pint  of  water.  Tannate  of  alumina  is  formed  by  chemical 
decomposition.  It  should  be  I'ecollected,  however,  that  tannin,  and  the 
salts  which  contain  it,  stain  the  linen  almost  as  indelibly  as  nitrate  of 
silver,  which  is  a  serious  objection  with  many  women  to  its  use.  I  have 
also  employed  injections  of  the  sulphate  and  acetate  of  zinc,  and  subace- 
tate  of  lead,  with  satisfactory  results.  Labarraque's  solution  of  chlorinated 
soda,  diluted  with  from  eight  to  twelve  parts  of  water,  may  be  injected, 
when  the  discharge  is  very  ofi'ensive.  A  solution  of  chloride  of  zinc,  of 
the  strength  of  fi'om  one  to  three  grains  to  the  ounce  of  water,  is  a  favorite 
injection  with  some  surgeons. 

The  following  formula,  intended  as  a  substitute  for  the  aromatic  wine 
of  the  French  Pharmacoprcia,  is  one  of  the  best  injections  for  general 
use : — 

R.     Claret  Wine, 

Compound  Spirits  of  Lavender,  a.i  ^v  150 

Tincture  of  Opium  §ss 15 

Water  '^iijss 105 

Tannin  5j— §j 4      — 30| 

M. 

I  usually  direct  the  patient  to  add  two  tablespoonfuls  of  this  mixture  to 
a  tumblerful  of  water,  and  to  gradually  increase  the  strength. 

I  rarely  prescribe  a  solution  of  nitrate  of  silver  for  the  patient's  own 
emjjloyment,  but  frequently  myself  apjdy  it  to  the  vaginal  walls,  by  first 
introducing  a  glass  speculum  as  far  as  the  cervix  uteri,  and  then  pouring 
a  few  drachms  through  the  instrument.     If  the  speculum  be  slowly  with- 

'  Pathology  and  Treatment  of  Leucorrlioca,  p.  183. 


TREATMENT.  205 

drawn,  the  fluid  will  come  in  contact  with  the  whole  extent  of  the  vagina. 
I  regard  this  method  as  one  of  special  value,  for  if  the  patient  lie  on  her 
back  with  the  pelvis  well  elevated,  and  if  the  speculum  be  as  large  as  the 
parts  will  admit,  the  force  of  gravity  carries  the  solution  into  every  recess 
of  the  dilated  vagina,  and  insures  its  thorough  application  to  this  canal, 
and  also,  in  a  measure,  to  the  cavity  of  the  cervix.  The  parts  should  be 
thoroughly  cleansed  with  copious  injections  of  simple  water,  before  the 
speculum  is  introduced.  In  this  manner,  a  solution  of  nitrate  of  silver, 
containing  9j-iij  to  the  ounce,  may  be  applied  by  the  surgeon  every  third 
or  fourth  day,  and  the  patient  at  the  same  time  use  some  mild  astringent 
injection  twice  a  day. 

An  ap[)lication  of  the  solid  nitrate  of  silver  crayon,  a  favorite  method  of 
treatment  among  Frencli  surgeons,  is  requisite  in  some  cases  which  do  not 
improve  under  a  solution  of  the  same  salt.  The  deepest  folds  of  the 
vagina  should  be  exposed  by  means  of  a  bivalve  speculum,  and  the  caustic 
applied  to  the  mucous  membrane  covering  the  cervix,  and  to  that  of  the 
vaginal  walls,  as  they  are  brought  into  view  by  the  gradual  Avithdrawal  of 
the  instrument.  The  compound  tincture  of  iodine,  pencilled  over  the 
surface  with  a  camel's-hair  brush  attached  to  a  long  handle,  is  sometimes 
preferable  to  the  lunar  caustic. 

The  contact  of  purulent  matter  with  the  mucous  membrane  of  the  geni- 
tal organs  is  doubtless  a  constant  source  of  irritation,  and  is  probably  suffi- 
cient to  account  for  some  of  the  superficial  abrasions  and  other  lesions, 
revealed  by  a  specular  examination.  The  collection  and  retention  of  pus 
upon  the  external  integument  will  soon  excoriate  the  surface,  and,  with 
still  greater  reason,  may  it  be  supposed  to  act  thus  upon  the  more  delicate 
mucous  membrane.  The  abrasions,  once  formed,  increase  the  quantity  of 
the  discharge  by  their  own  secretion,  and  thus  the  two  react  upon  each 
other,  and  prolong  the  disease.  The  evil  is  easily  remedied  in  balanitis 
and  vulvitis  by  interposing  between  the  inflamed  surfaces  some  porous 
material,  ca[)able  of  absorbing  the  discharge  as  f;ist  as  it  is  secreted,  and 
M'et,  if  desired,  with  an  astringent  lotion,  which  will  exert  a  constant 
medicinal  effect  upon  the  mucous  membrane.  The  same  result  may  be 
attained  in  vaginitis,  and  has  even  been  attempted  in  gonorrhoea  of  the 
cervix.^  For  tJiis  purpose  a  folded  piece  of  lint  is  sometimes  used,  but  a 
plumasseau  of  charpie  or  carded  cotton  is  preferable,  since  it  retains  its 
elasticity  to  a  greater  degree,  and  is  a  better  absorbent.  It  may  first  be 
rolled  in  the  following  powder:  — 

I^.     Powdered  Starch  §j 30] 

Tannin  _^v 20 

Powdered  Alum  5iss 6] 

M.  (Diday.) 

To  facilitate  its  withdrawal,  a  small  string  may  be  previously  attached 
to  it.      The  size  of  this  tam[)on  must  be  proportioned  to  the  dimensions  of 

'  Hoi'RMAxx.  Tainponnemcnt,  comme  methode  de  traitement  dos  ecouleiuents 
utero-vaginaux.     J.  d.  conn,  med.-chir.,  Paris,,  mars,  1841,  p.  89. 


206  GONORRIICEA    IN    AVOMEN. 

the  vagina  in  each  case,  and  will  vary  in  diameter  from  half  an  inch  to 
two  inches.  In  some  instances  it  is  medicated  ;  in  others,  not.  In  the 
former  case,  the  medicinal  substance  may  be  an  absorbent  or  astringent 
j)0\vder,  as  prepared  chalk,  subnitrate  of  bismuth,  calamine,  tannin,  pow- 
dered alum,  etc.  ;  or,  it  may  consist  of  any  of  the  lotions  which  have  been 
recommended  for  the  purposes  of  injections  either  in  the  male  or  female. 
Calamine  and  powdered  alum  are  the  best  dry  preparations,  and  a  solution 
of  tannin  in  glycerine  (5j-'j  ^^  5J)  an  excellent  fluid  astringent.  The 
plug  may  be  inserted  by  the  surgeon  through  a  speculum,  or  the  patient 
may  be  taught  to  introduce  it  with  her  finger,  or  by  means  of  a  stylet.  It 
should  be  withdrawn  at  the  end  of  twelve  hours,  the  vagina  Avashed  out 
with  a  copious  injection,  and  a  fresh  plug  introduced,  or  the  latter  maybe 
deferred  till  the  following  day. 

Scanzoni  employs  a  plug  of  cotton  wool,  sprinkled  with  alum  powder, 
either  pure  or  mixed  with  one  or  two  parts  of  sugar.  Pure  alum  is  liable, 
on  the  second  or  third  application,  to  excite  a  very  disagreeable  sensation 
of  heat  and  constriction  in  the  vagina,  rendering  it  necessary  to  suspend 
the  treatment  for  a  week  or  two ;  hence  it  is  not  to  be  used  undiluted, 
unless  the  parts  are  quite  insensible  ;  and  on  this  account,  therefore,  it  will 
be  best  to  try,  in  the  majority  of  cases,  a  mixture  of  alum  and  sugar.  The 
plug,  thus  prepared,  should  not  be  used  oftener  than  every  second  or  third 
day,  nor  be  allowed  to  remain  in  longer  than  two  or  three  hours,  since  it 
soon  becomes  soaked  with  the  vaginal  secretion,  and  lukewarm  or  cold 
water  should  be  injected  immediately  on  its  withdrawal.  If  these  precau- 
tions be  neglected,  acute  inflammation  of  a  troublesome  character  may  be 
excited,  and  the  discharge  augmented  instead  of  diminished.^ 

Simpson,  of  Edinburgh,  has  proposed  an  efficacious  mode  of  keeping  an 
astringent  in  constant  contact  with  the  vaginal  walls,  by  means  of  pessa- 
ries, prepared  according  to  the  following  formulae : — 

I^.     Acidi  Tannicigij 2160 

Cei-ffi  Alba?  9v       .     .     • G  50 

Axungise  ^vi 24] 

Misce,  et  divide  in  Pessos  quatuor.  , 

l^.     Aluminis  3j 4 

Pulveris  Catechu  5j 4 

Cerje  Flavje  5j 4 

Axuiigife  5vss 22 

Misce,  et  divide  in  Pessos  quatuor. ^ 

Hip-baths,  taken  every  morning  on  rising  or  in  the  early  part  of  the 
day,  are  valuable  adjuvants  in  the  treatment  of  chronic  vaginitis.  The 
temperature  of  the  bath  should  be  determined  in  part  by  the  season  of  the 
year,  and  in  part  by  the  strength  and  habits  of  the  patient.  It  is  well  to 
commence  with  lukewarm  water,  and  gradually  lower  the  temperature  as 
the  system  becomes  accustomed  to  them  ;  but  they  should  never  be  so  cold 

'  Op.  cit.,  p.  450. 

2  Edinburgli  Monthly  Journal,  June,  1848,  and  Obstetric  Works,  p.  98. 


TREATMENT.  SOT 

nor  continued  so  long  that  the  patient  feels  chilly  for  some  time  after  their 
employment,  and  reaction  should  be  promoted  by  friction  with  a  coarse 
towel,  flesh-brush,  or  hair-mitten.  These  baths  may  be  rendered  still  more 
effectual  by  the  addition  of  a  handful  of  coarse  salt  to  each  bucket  of  water 
used.  Astringents,  as  alum,  in  the  proportion  of  half  a  pound  to  each  bath, 
are  also  recommended  by  some  authors. 

The  hygienic  management  of  the  case  should  always  receive  special 
attention  in  chronic  vaginitis.  As  the  inflammatory  symptoms  of  the 
acute  stage  subside,  the  patient  may  be  allowed  a  more  generous  diet  and 
greater  freedom  of  motion,  but  she  should  still  avoid  violent  or  prolonged 
exercise,  and  especially  all  sexual  excitement.  Walking  and  even  standing 
for  any  length  of  time  should  be  but  moderately  practised  at  this  stao-e  of 
the  affection.  No  absolute  rules  can  be  laid  down  for  diet,  which  should 
be  adapted  to  each  individual  case.  In  general,  the  food  should  be  plain 
and  simple,  and  yet  sufficiently  nourishing,  and  the  meals  should  be  taken 
at  regular  hours.  Higlily  seasoned  dishes,  pastry,  and  meats,  cheese,  and 
strong  tea  and  coffee,  should  be  forbidden ;  and  bread,  eggs,  fresh  meat 
once  a  day,  vegetables,  and  simple  puddings,  recommended.  Regularity 
of  the  bowels  should  be  secured,  if  necessary,  by  small  doses  of  saline 
cathartics,  taken  on  rising  in  the  morning;  and,  in  brief,  all  such  measures 
should  be  adopted  as  are  calculated  to  bring  the  general  health  to  the  best 
possible  condition.  The  latter  rule  implies  that  the  system  should  neither 
be  stimulated  above,  nor  depressed  below,  the  happy  mean;  yet,  at  the 
same  time,  there  are  but  few  cases  of  chronic  vaginitis  which  do  not  re- 
quire some  sui)port,  and  in  which  either  mineral  acids,  preparations  of  iron, 
vegetable  tonics,  quinine,  or  even  stimulants,  are  not,  at  some  period,  in- 
dicated. 

The  formula?  for  various  tonics,  already  given  when  treatino-  of  this 
disease  in  the  male  sex,  are  equally  api)licable  to  the  female.  The  only 
one  which  I  would  add  at  present  is  the  following  old  but  excellent  com- 
bination of  a  tonic,  cathartic,  and  astringent.  Its  cheapness  recommends 
it  especially  for  the  poorer  class  of  patients,  while  for  those  in  better  cir- 
cumstances a  more  palatable  substitute  may  be  found  in  Seidlitz  powders 
or  citrate  of  magnesia,  taken  on  rising  from  bed,  and  in  the  French  dragees 
of  iron  administered  just  before  or  after  meals. 

R.     Magnesi:e  Sulphatis  §iss      .     .       45 
Ferri  Sulphatis  9ij     .     .     .     .         2  60 
Acidi  Siiljihurici  gtt.  x    .     .     .  (jS 

Iiifusionis  Geutianje  Comj).  Oj       500 
M. 
A  tablespoonful  three  times  a  day. 

In  gonorrhoea  of  the  vulva  lotions  may  be  applied  with  great  facility, 
and  the  parts  separated  by  the  interposition  of  lint  or  charpie.  Cauteriza- 
tion with  the  solid  nitrate  of  silver  or  a  solution  of  this  salt  is  often  bene- 
ficial. Resolution  of  a  commencing  abscess  of  the  vulvo-vaginal  'dand 
or  duct  may  sometimes  be  obtained  by  rest,  cathartics,  an  antiphlogistic 
regimen,  and  the  application  of  ice,  assisted,  in  some  cases,  by  tlie  appli- 
cation of  Jeeches  to  some  adjacent  part.     If  suppuration  takes  place,  the 


208  GONORRH(EA    IN    WOMEN. 

abscess  should  be  opened  without  deUiy.  Ricord,  Vidal,  Zeissl,and  others 
advise  making  the  incision  upon  the  external  surface  of  the  labium,  to 
avoid  tlie  admission  of  the  urine  and  discharges,  which  would  irritate  the 
cavity  of  the  abscess  and  prevent  its  healing.  An  incision  in  this  situation, 
however,  often  fails  to  prevent  a  spontaneous  opening  on  the  mucous  sur- 
face, where  the  abscess  naturally  tends  to  point.*  By  making  a  small 
incision  on  the  internal  and  inferior  aspect  of  the  tumor,  and  directing 
the  knife  somewhat  u[)wards  so  that  the  cut  shall  be  valvular,  and  also  by 
allowing  the  abscess  to  evacuate  itself  by  the  contraction  of  its  walls  with- 
out the  exercise  of  pressure,  the  entrance  of  foreign  matter  may  generally 
be  prevented.  In  case  the  abscess  repeatedly  recurs,  its  exact  seat  should 
be  carefully  ascertained.  If  it  occupy  the  duct,  it  should  be  laid  oi)en  by 
a  free  incision,  and  the  cavity  filled  up  with  lint.  If  it  be  seated  in  the 
gland,  this  must  be  dissected  out.  I  have  tried,  in  several  instances,  to 
cure  these  abscesses  by  the  introduction  of  a  seton,  but  have  always  failed. 

Whenever,  after  an  attack  of  vulvitis,  there  still  remains  a  ])urulent 
discharge  from  the  vulvo-vaginal  duct,  and  also  in  the  cases  described  by 
Dr.  Salmon  in  which  this  part  is  primarily  affected,  a  solution  of  nitrate 
of  silver  may  be  injected  by  means  of  Anel's  syringe. 

In  gonorrhvea  of  the  uterus,  the  os  should  be  dilated  if  necessary  by 
means  of  sponge  tents,  and  the  cavity  of  the  cervix  and  body  of  the  uterus 
be  freely  cauterized  with  the  solid  nitrate  of  silver.  A  crayon  of  this  salt 
may  be  passed  up  with  forceps  into  the  uterine  cavity;  or  the  extremity 
of  a  uterine  sound  or  Lente's  probe'' may  be  coated  with  the  nitrate  melted 
over  a  spirit-lamp,  and  be  made  to  sweep  over  the  whole  affected  surface. 
No  danger  need  be  feared  even  if  the  crayon  of  the  nitrate  should  break, 
and  a  portion  be  left  within  the  uterus.  The  application  should  be  re- 
peated every  third  or  fourth  day,  and  astringent  vaginal  injections  be  still 
continued.  Intra-uterine  injections  are  never  admissible,  as  they  have 
repeatedly  proved  fatal. 

Whenever,  in  gonorrlitea  of  the  vagina  or  uterus,  the  cervix  is  found 
enlarged  and  congested,  from  four  to  six  leeches  may  be  applied.  They 
are  especially  applicable  at  the  outset  of  the  treatment,  and  may  require  \o 
be  repeated  once  or  twice  at  intervals  of  a  week  ;  but  the  patient  should 
not  be  debilitated  by  tlieir  frequent  use.  Tiie  surgeon  should  apply  them 
himself,  taking  care  to  plug  the  cervix  beforehand,  that  tiiey  may  not 
fasten  upon  the  sensitive  membrane  of  its  internal  surface.  If  the  flow  of 
blood  is  excessive,  it  may  be  arrested  by  cold  injections  of  a  solution  of 
alum. 

The  acute  stage  of  urethritis  is  of  so  short  duration  as  to  demand  but 
little  special  treatment.  In  most  cases,  the  measures  adopted  for  the  con- 
comitant inflammation  of  the  vulva,  vagina,  or  uterus,  aided,  perhaps,  by 

'   Huguior,  op.  cit.,  p.  343. 

Diday  also  rcconimonds  the  incision  to  be  made  on  the  mucous  surface.  Diday 
and  Doyon,  Mai.  v6n.  et  cutanees,  187(i,  p.  119. 

2  A  new  Uterine  Porte-Caustique,  by  Fred.  D.  Lente,  M.D.  ;  American  Med. 
Times,  Sept.  2C,  1863. 


LATENT    GONORRHCEA    IN    WOMEN.  209 

the  administration  of  alkalies,  neiitral  salts,  or  sedatives,  are  sufficient  to 
effect  a  decided  amelioration,  and  often  the  entire  disappearance  of  the 
disease.  When  this  result  fails  to  be  attained,  I  do  not  hesitate  to  resort 
to  injections,  as  in  urethral  gonorrhoea  in  men  ;  but  as  they  cannot  be  used 
by  the  patient,  it  is  necessary  for  the  surgeon  to  administer  them  himself. 
Their  active  principle  may  be  one  of  the  salts  of  lead  or  zinc,  or  tannin ; 
or  from  one  to  two  drachms  of  a  solution  of  nitrate  of  silver,  containing  ten 
or  twenty  grains  to  the  ounce,  may  be  thrown  in.  If,  in  this  case,  we 
carefully  guard  against  having  the  bladder  entirely  empty,  no  evil  result 
need  be  feared.  CuUerier,  in  gonorrhoea  of  the  female  urethra,  does  not 
hesitate  to  cauterize  the  whole  length  of  the  canal  by  means  of  a  crayon  of 
nitrate  of  silver  sufficiently  large  to  distend  the  passage.^ 

Copaiba  and  cubebs  may  also  be  employed  in  this  alFection,  administered 
in  the  manner  directed  for  men.  liicord's  experiments  have  shown  that 
their  effect  in  gonorrhoea  of  any  portion  of  the  genital  organs  not  traversed 
by  the  urine  is  so  slight  that  they  are  not  to  be  recommended  in  vaginitis 
or  vulvitis.  Indeed,  they  can  readily  be  dispensed  with  in  all  forms  of 
gonorrhoea  in  women. 

"  Latent  Gonorrhcea  in  "Women." — A  remarkable  pamphlet  was 
published  in  the  German  language,  at  Bonn,  in  1872,  by  Dr.  Emil  Noeg- 
gerath,  of  New  York,  and  has  been  supplemented  by  an  article  in  the  first 
volume  of  the  Transactions  of  the  Am.  Gynaecological  Soc.  (1876). 

In  these  articles  Dr.  N.  advocates  the  existence  of  a  so-called  latent 
gonorrhoea  in  both  sexes;  in  other  woi'ds,  he  claims  that  gonorrlioea  in  both 
man  and  woman  is  never  cured,  even  if  all  appreciable  signs  of  its  existence 
have  disappeared ;  that  in  man  the  inflammation  always  extends  into  the 
spermatic  ducts,  vas  deferens  and  epididymis,  and  in  woman  into  the  uterus 
and  Fallopian  tubes;  that,  though  it  may  be  cured  in  those  portions  of  the 
genital  track  which  can  be  reached  by  local  applications,  it  still  lingers  in 
the  inaccessible  portions  just  mentioned,  preserving  its  contagious  property, 
and  ready  to  break  out  again  in  an  acute  form  upon  slight  provocation ; 
that  in  this  way  may  be  explained  the  cases  in  which  men  contract  gonor- 
rhoea from  apparently  healthy  women  ;  and  finally,  that  this  latent  disease 
in  men  is  communicated  by  them  to  their  wives  after  marriage  in  some 
latent  way — latent,  because  the  women  show  at  the  time  no  sign  of  infec- 
tion— and  manifests  itself  at  some  time  or  other  in  one  of  those  troublesome, 
tedious,  and  even  fatal  affections  to  which  women  are  subject,  and  among 
wliicli  Dr.  N.  mentions  acute  perimetritis,  recurrent  perimetritis,  chronic 
perimetritis,  ovaritis,  and  puerperal  fever ;  such  women  are  said  also  to  be 
commonly  sterile."  All  this  in  consequence  "of  the  gradual  infection  (?) 
of  the  woman  by  repeated  contact  with  minute  quantities  of  the  poison" 

•  Des  affections  lih*nnorrliagiqiies,  p.  r)8. 

2  "  The  wives  of  men  who  at  any  time  of  their  lives  have  had  gonorrlioea,  are, 
as  a  rule,  sterile."     These  words  constitute  one  of  Dr.  N.'s  conchisions.     Again 
he  says  :   "  About  ninety  per  cent,  of  sterile  women  are  married  to  husbands  who 
have  suffercV.  from  gonorrhoea  either  previous  to  or  during  married  life." 
14 


210  GONORRHCEA    TN    WOMEN. 

Dr.  Noeggerath  founds  his  conclusions  upon  the  cases  of  the  al)ove- 
mentioned  diseases  and  the  cases  of  sterility  which  have  come  under  his 
treatment,  and  in  which  inquiry  into  the  history  of  the  husbands  has  shown 
in  nearly  every  instance  that  they  had  had  at  some  time  in  their  lives  one 
or  more  attacks  of  gonorrlujea,  of  which  perhaps  they  had  not  perceived  the 
slightest  trace  for  months  or  years. 

It  is  a  little  singular  that  Dr.  N.  did  not  perceive  the  fallacy  of  reason- 
ing on  the  principle  of  po^t  hoc  ergo  propter  hoc  in  these  cases.  He 
explicitly  states  that  he  believes  with  Ricord  that  800  out  of  every  1000 
men  have  had  gonorrhoea.  Let  us  then  apply  the  same  reasoning  to  1000 
women,  who  have  remained  healthy  after  their  marriage,  and  who  have 
"  replenished  the  earth"  with  many  quiverfuls  of  offspring.  Eight  hun- 
dred of  their  husbands  must  have  had  gonorr]ia?a  at  some  time  in  their 
lives;  hence  gonorrhoea  is  greatly  conducive  to  fecundity!  Post  hoc  ergo 
propter  hoc. 

At  a  recent  meeting  of  the  British  Medical  Association  it  was  announced 
by  one  of  the  speakers  that  Dr.  N.'s  views  were  so  generally  known  and 
accepted  in  America  that  one  of  the  first  questions  asked  by  the  parents 
of  every  young  lady  to  whom  marriage  was  proposed  by  a  gentleman,  was 
whether  he  had  ever  had  the  clap  ! 

Let  any  specialist  in  diseases  of  the  male  genital  organs  inquire  of 
married  men  coming  to  his  olfice  whether  they  ever  had  the  clap,  and, 
if  so,  if  their  wives  have  since  been  healthy  and  borne  children,  and  he 
will  find  the  answers  not  corroborative  of  Dr.  N.'s  views.  In  short, 
even  if  800  out  of  1000  men  have  had  the  clap,  the  human  race  did  not  die 
out  long  ago,  but  still  exists,  and  shows  no  tendency,  so  far  as  I  know,  to 
diminution. 


GONORRH(EA    OF    THE    RECTUM,    MOUTH,    NOSE,    ETC.  211 


CHAPTER   XIX. 

GONORRHCEA    OF   THE   RECTUM,    MOUTH,    NOSE, 
AND    UMBILICUS. 

These  extra-genital  forms  of  gonorrhoea  are  rarely,  if  ever,  met 
with,  and  the  existence  even  of  the  last  three  may  well  be  called  in  ques- 
tion. With  tlie  exception  of  the  ocular  conjunctiva  all  other  mucous 
membranes  external  to  the  genital  organs  show  a  very  great  inaptitude  to 
take  on  inflammation  from  contact  with  gonorrhoeal  matter. 

M.  Diday^  details  some  experiments  on  this  point.  He  says:  "Wishing 
to  assure  myself  of  the  existence  of  these  affections,  I  have  often  (cer- 
tainly more  than  thirty  times)  conveyed  on  the  end  of  my  finger  the  ure- 
thral discharge  of  patients  to  their  noses,  lips,  and  the  folds  within  the 
anus,  and  rubbed  it  in!  They,  not  suspecting  what  I  had  done,  took  no 
precautions  to  avert  the  consequences,  and  yet  I  have  never  seen  anyeft'ect 
produced." 

The  one  of  the  above  forms  of  gonorrhoea  whose  existence  is  best  estab- 
lished is 

GONORRH<£A    OF    THE    ReCTUM. 

I  have  never  met  with  an  instance  of  this  affection,  and  I  must  therefore 
rely  upon  other  authors  for  an  account  of  its  symptoms  and  treatment. 

Gonorrhoeal  inflammation  of  the  rectum  may  arise  eitlier  from  the  act  of 
Sodomy,  or  from  the  inoculation  of  the  rectal  mucous  membrane  by  means 
of  a  gonorrhoeal  discharere  flowing  from  the  genital  organs. 

The  existence  of  this  affection  a[)pears  now  to  be  well  authenticated, 
but  its  occurrence  is  extremely  rare  even  in  those  countries,  as  South 
America,  whei'e  unnatural  modes  of  coitus  abound. 

Both  sexes  are  equally  exposed  to  it  in  the  mode  of  its  origin  first  men- 
tioned, viz.:  Sodomy;  in  the  second  mode,  extension  of  a  gonorrho'al 
discharge  from  the  genital  organs,  it  is  evident  that  women  run  a  much 
greater  risk  than  men,  on  account  of  tlie  facility  with  which  secretions 
flowing  from  the  vulva  may  extend  to  the  perina?um  and  the  margin  of  the 
anus.  It  is  also  evident  that  the  presence  of  protruding  piles  or  eversion 
of  the  rectal  walls  will  greatly  favor  contagion. 

In  cases  of  this  kind,  tlie  patient  complains  of  a  constant  burning  and 
itching  sensation  about  tlie  anus,  and  a  frequent  call  to  stool;  decided  pain 
is  experienced  only  on  the  passage  of  the  feces.     The  discharge  is  puru- 
• 

'  DiDAY  and  Doyon  (op.  cit.),  p.  129. 


212  GONORRHCEA    OF    THE    RECTUM,    MOUTH,    NOSE,    ETC. 

lent,  oftensive,  and  often  bloody,  and  tends  to  ooze  constantly  from  the 
anal  orifice,  but  it  a[)pears  in  larger  quantities  before  defecation  or  on  pass- 
ing flatus;  the  margin  of  the  anus  and  the  skin  of  the  perina;um  are  irri- 
tated and  excoriated  by  its  contact.  In  severe  cases  the  mucous  membrane 
of  the  bowel  becomes  much  swollen  and  protrudes  from  the  orifice  ;  and 
fissures  and  excoriations  may  occur  in  the  rectal  and  anal  folds.  Vegeta- 
tions are  another  unpleasant  sequela,  and  may  attain  such  a  size  as  to  in- 
terfere with  the  passage  of  the  stools. 

So  far  as  known,  gonorrhoea  of  the  rectum  does  not  run  into  a  chronic 
form  corresponding  to  gleet  of  the  urethra;  chronic  inflammation  of  this 
gut,  attended  by  a  foul,  muco-purulent  discharge  and  uneasy  sensations  in 
the  part  is  commonly  due  to  piles. 

Treatment In  the  treatment  of  this  affection,  the  patient  should  be 

confined  to  the  house,  and,  if  possible,  to  the  recumbent  posture ;  enemata 
of  some  strong  astringent  lotion,  as  of  alum,  should  be  administered  several 
times  a  day  ;  sitz-baths  or  baths  with  full  immersion  of  the  body  may  prove 
grateful  and  beneficial.  The  insertion  into  the  rectum  of  pledgets  of  lint, 
either  medicated  or  not,  between  the  stools,  has  been  recommended  on  the- 
oretical grounds,  but  must  for  evident  reasons  be  put  in  practice  with  great 
difficulty.  The  frequency  of  the  discharges  from  the  bowels  should  be 
regulated  by  opium  in  accordance  with  the  general  condition  of  the  patient, 
and  the  condition  of  the  diseased  parts  as  affected  by  the  passage  of  the 
feces;  local  rest  being  of  course  desirable,  unless  contraindicated. 

Fissures  and  excoriations  of  the  anus  produced  by  gonorrhoea  of  the 
rectum  may  be  pencilled  if  necessary  with  a  solution  of  nitrate  of  silver; 
vegetations  are  likely  to  persist  and  are  subject  to  the  treatment  elsewhere 
described. 

Mr.  Allingham,  in  his  most  excellent  work  on  the  diseases  of  the  rec- 
tum, thus  speaks  of  this  affection  : — 

"I  have  had  under  my  care  three  cases  of  undoubted  gonorrhoea  of  the 
rectum.  There  was  great  heat  and  burning  pain  experienced,  wdth  a 
copious  discharge  of  pure  pus ;  the  mucous  membrane,  as  seen  through  the 
speculum,  w^as  intensely  inflamed ;  the  cases  occurred  in  prostitutes,  who 
all  confessed  the  manner  in  which  they  got  so  affected.  The  cui'e  was  not 
difficult ;  lead-lotion  and  opium  was  used  in  two  cases,  and  answered  very 
well;  the  third  was  treated  by  sulphate  of  zinc  and  warm  water  injected 
three  times  daily;  in  neither  case  was  there  any  ulceration  of  the  lining 
membrane  of  the  bowel,  nor  did  any  thickening  or  contraction  result;  the 
inflammation  did  not  appear  to  affect  the  submucous  areolar  tissue." 
(Allingham  on  Diseases  of  the  Rectum,  1871,  p.  237.) 

Gonorrhoea  of  the  Mouth. 

Holder*  states  that  this  aflfection  may  arise  from  direct  contact  of  the 
mouth   with    the   genital   organs,   and  says    that    Petrasie,  of   Kiel,  had 

1  Lehrbuch  der  venerischen  Krauklieiten,  Stuttgart,  1851,  i>.  288. 


GONORRn(EA    OF    THE    RECTUM,    MOUTH,    NOSE,    ETC.  213 

recently  reported  the  case  of  a  young  man  who  confessed  having  exposed 
himself  in  this  manner.  On  the  following  day  he  had  pain  in  the  lips  and 
gums.  On  the  fourth  day  the  mucous  membrane  of  the  lips  and  buccal 
cavity  became  intensely  red;  motion  of  the  mouth  was  painful;  the  gums 
were  spongy,  inclined  to  bleed,  and  a  little  receding  from  the  teeth,  and 
the  buccal  secretion  was  increased  in  quantity.  Other  authors  speak  of  a 
copious  puriform  secretion  and  aphthous  exudations.  Potrasie's  case  is 
said  to  have  been  cured  in  a  week  by  means  of  an  alum  gargle. 

Gonorrhoea  of  the  Nose. 

A  case  of  this  kind  is  reported  by  Mr.  Edwards.^  Holder  (op.  cit.,  p. 
288)  also  speaks  of  it.  It  is  said  that  it  may  arise  either  from  the  matter 
of  gonorrhceal  ophthalmia  flowing  down  upon  the  nares  or  from  the  use 
of  a  napkin,  or  the  fingers  soiled  with  the  same;  that  generally  only  one 
nostril  is  affected;  that  the  symptoms  are  about  the  same  as  a  very  severe 
"  cold  in  the  head ;"  that  there  is  but  little  pain ;  and  that  it  is  readily 
cured  by  cold  applications,  snuffing  up  cold  water,  pencillings  with  a  solu- 
tion of  nitrate  of  silver  and  afterwards  the  use  of  an  alum  or  borax  lotion. 

Umbilical  Gonorrhcea. 

A  young  man,  aged  10,  was  found  by  Morrison^  to  have  urethral  gonor- 
rhoea and  at  the  same  time  a  similar  discharge  from  the  umbilicus,  which 
was  relieved  by  solutions  of  acetate  of  lead  and  sulphate  of  zinc. 

'  London  Lancet,  Am.  reprint,  June,  1857. 
2  Bull.  med.  du  Nord,  Lisle.     No.  10,  1874. 


214  GONORRH(EAL    OPHTHALMIA. 


CHAPTER    XX. 

GONORRHCEAL   OPHTHALMIA. 

GoNORRH<EAi,  Ophthalmia  lias  been  supposed  to  originate  in  three  ways — 
from  inoculation,  from  metastasis,  and  from  sympathy,  each  of  which  has 
from  time  to  time  been  received  by  certain  authors  as  its  exclusive  mode 
of  origin. 

The  occurrence  of  gonorrhoeal  ophthalmia  from  inoculation  or  contagion, 
cannot,  at  the  present  day,  be  called  in  question.  Numerous  cases  re- 
ported by  Mackenzie,  by  Lawrence,  and  by  nearly  every  modern  writer  on 
diseases  of  the  eye,  leave  no  room  to  doubt  that  tlie  discharge  of  gonor- 
rh(x^a  applied  to  the  ocular  conjunctiva,  may  set  up  a  severe  and  destructive 
form  of  inflammation,  similar  to  if  not  identical  with  purulent  conjuncti- 
vitis. But,  besides  these  reports  of  cases  in  which  the  inoculation  has 
been  tlie  result  of  accident,  further  proof  is  to  be  found  in  the  treatment  of 
pannus,  employed  of  late  years  chiefly  by  French  and  German  surgeons, 
in  which  the  eyes  have  been  intentionally  inoculated  with  the  pus  of  gonor- 
rhoea. Discharges  from  the  genital  organs  have  been  transferred  to  eyes 
affected  with  pannus,  with  the  express  design  of  exciting  acute  inflamma- 
tion, which,  it  was  hoped,  might  cure  the  chronic  disease;  and,  however 
questionable  may  have  been  the  results  of  this  practice,  so  far  as  the  ac-  - 
complishment  of  the  latter  purpose  is  concerned,  there  has  been,  at  all 
events,  no  difficulty  in  producing  acute  inflammation  by  such  inoculation. 
With  these  facts  before  us,  therefore,  no  further  doubt  of  gonorrhccal  oph- 
thalmia from  contagion  is  admissible ;  indeed,  direct  inoculation  is  now 
regarded  by  all  surgeons,  with  but  few  exceptions,  as  the  only  mode  in 
which  originates  that  destructive  form  of  conjunctivitis  which  sometimes 
attends  gonorrhoea. 

The  old  idea  of  a  metastatic  origin  of  gonorrhoeal  ophthalmia,  first 
advanced  by  St.  Yves,^  is  now  completely  abandoned,  and  the  same  is  true 
of  "sympathy"  as  a  supposed  cause. 

Frequency. — Gonorrhoeal  ophthalmia,  compared  with  the  frequency 
of  gonorrhoea,  is  a  rare  affection.  The  following  table  exhibits  the  number 
of  cases  received  at  the  N.  Y.  Eye  Infirmary  during  a  period  of  fifteen 
consecutive  years,  and  the  proportion  which  these  cases  bear  to  the  whole 
numljer  of  patients. 

'  A  New  Treatise  of  the  Diseases  of  the  Eyes,  by  M.  De  St.  Yves,  Surgeon  Oculist 
of  tlie  Company  of  Paris,  translated  from  the  original  French  by  J.  Stockton,  M.D., 
London,  1741,  p.  Iti8. 


CAUSES. 


215 


Ykar. 
3  845 
1846 
1847 
1848 
1849 
1850 
1851 
1852 
1853 
1854 
1855 
1856 
1857 
1858 
1859 


)r,E  NUMBER      Cases  OF  GONORRHCKAL 

?  Patiexts.  Ophthalmia. 


Total 


1366 
1245 
1485 
1815 
1902 
2082 
2472 
2732 
2719 
2635 
2652 
2634 
3216 
3908 
4171 

37,034 


2 
3 

2 
5 
3 
3 
6 
7 
5 
6 
5 
4 
3 
2 
3 

59 


It  thus  appears  that,  compared  with  the  whole  number  of  diseases  of 
the  eye  treated  at  this  institution,  cases  of  gonorrhoeal  ophthalmia  are  only 
as  1  to  028.  We  have  no  statistics  by  which  to  determine  the  exact  ratio 
of  this  disease  to  the  whole  number  of  cases  of  gonorrhoea;  yet  I  think 
the  experience  of  every  physician  would  lead  him  to  infer  that  it  is  not 
much  greater  than  to  diseases  of  the  eye,  since  gonorrhoea  must  be  nearly 
as  frequent  as  all  ocular  aiFections  combined. 

Causes The  contagious  matter  which  has  produced  acute  inflamma- 
tion of  the  conjunctiva  in  a  given  case,  may  have  been  derived  from  the 
genital  organs  or  from  the  opposite  eye — already  affected  with  gonorrhceal 
ophthalmia — of  the  same,  or  from  those  of  another  person.  In  many  of 
the  reported  cases  of  this  disease,  the  ophthalmia  has  been  produced  by 
patients  washing  their  eyes  in  their  own  urine,  with  which  gonorrhfcal 
pus  was  mixed,  or  by  otherwise  applying  the  discharges  from  their  own 
persons. 

The  personal  habits  of  those  affected  with  gonorrhoea,  and  the  degree 
of  intimacy  existing  between  members  of  the  same  household,  will,  in  a 
great  measure,  determine  the  frequency  of  infection.  Among  the  poor 
and  squalid,  where  cleanliness  is  neglected  and  the  same  vessels  and  towels 
are  used  in  common,  gonorrhoeal  ophthalmia  may  readily  be  communicated 
from  one  individual  to  another,  until  it  has  attacked  all  the  members  of 
tiie  same  family. 

Ricord  states  that  he  has  never  seen  gonorrhoeal  ophthalmia  produced 
by  discharges  from  any  portion  of  the  genital  organs  except  the  urethra ; 
and  that  he  lias  never  known  it  to  be  caused  by  the  i)us  of  balanitis  or 
vaginitis.  There  is  reason  to  believe,  however,  tliat  a  simply  vaginal  dis- 
charge is  capable  of  exciting  the  disease  under  consideration. 

It  is  a  well  established  fact  that  "  ophthalmia  neonatorum"  which,  like 
gonorrhoeal  ophtlialmia,  is  but  a  form  of  purulent  oi)ii(lialmia,  is  fretiuently 
caused  by  inoculation  of  the  infant's  eyes  with  leucorrlia'al  discharges  from 


216  GONORRIICEAL    OPHTHALMIA. 

the  mother.  I  have  repeatedly  seen  severe  purulent  conjunctivitis  in  very- 
young  girls,  Avho  were  affected  with  that  form  of  vaginitis  which  some- 
times attacks  children,  independently  of  contagion,  and  which  has  been 
so  ably  treated  of  by  Mr.  Wilde,  of  Dublin.  Analogous  cases  are  reported 
in  treatises  on  diseases  of  the  eye,  and  Dr.  Jiingken  mentions  one  instance, 
in  which  the  ophthalmia,  oi-iginating  in  this  manner,  spread  to  seven  mem- 
bers of  a  family.^ 

I  know  of  no  authentic  case  of  gonorrhoeal  ophthalmia  occasioned  by 
the  pus  of  balanitis.  Matter  from  a  venereal  or  ordinaiy  abscess  must 
also  be  regarded  as  generally  innocuous.  Yet  it  is,  perhaps,  impossible  to 
determine  with  accuracy  the  limits  within  which  purulent  matter  is  capa- 
ble of  exciting  severe  inflammation  of  the  conjunctiva.  The  predisposi- 
tion of  the  person  exposed  will  doubtless  have  no  small  influence  upon  the 
effect  produced.  Still,  so  far  as  at  present  known,  these  limits  are  con- 
fined to  the  urethra  and  vagina. 

The  inoculations  which  have  been  employed  in  the  treatment  of  pannus, 
will  throw  some  light  upon  the  conditions  under  which  contagion  may  be 
supposed  to  take  place.  The  puriform  matter  used  in  these  inoculations 
has  been  derived  either  from  the  genital  organs,  or  from  an  eye  affected 
with  gonorrhoea!  ophthalmia,  or  ophthalmia  neonatorum.  When  such 
matter  is  kept  from  contact  with  the  air,  it  is  found  to  retain  its  contagious 
property  for  about  sixty  hours.  If  exposed  to  the  air,  and  allowed  to  dry, 
it  soon  becomes  innocuous.  In  the  experiments  of  M.  Piringer,  of  CTratz, 
a  piece  of  linen  was  moistened  with  gonorrhoea!  matter,  and  allowed  to 
dry ;  the  cloth  was  then  rubbed  upon  the  eyes  of  several  persons,  and  no 
inoculation  ensued.  The  dried  matter  scraped  from  the  cloth,  and  applied 
directly  upon  the  conjunctiva,  took  effect  within  about  thirty-six  hours, 
after  it  was  first  obtained.  Matter,  once  dried  and  immediately  moistened 
again,  either  by  the  addition  of  water  or  by  contact  with  the  secretions  of 
the  eye,  was  found  to  be  contagious.  Fresh  matter  was  contagious,  even 
when  diluted  with  one  hundred  parts  of  water. 

Van  Roosbroeck  experimented  with  the  pus  of  a  common  abscess,  and 
found  that  it  was  innocuous  when  applied  to  the  eye.  This  surgeon  was 
also  led  to  the  conclusion  that  the  discharge  from  an  eye  affected  with  puru- 
lent ophthalmia,  diluted  with  water,  retains  its  power  of  contagion  until 
decomposition  has  begun  to  take  place,  as  shown  by  its  evolving  the  odor 
of  putrefaction. 

When  the  inoculation  is  successful,  no  disagreeable  sensation  is  at  first 
excited  by  the  application  of  the  matter ;  and  no  effect  is  perceived  until 
after  the  lapse  of  from  six  to  thirty  hours,  when  the  eye  begins  to  feel  hot, 
and  there  is  an  increase  in  the  ocular  secretions,  which  are  at  first  entirely 
mucous,  but  soon  become  muco-purulent. 

Gonorrhtcal  ophthalmia  is  much  more  common  in  men  than  in  women. 
Ricord  ascribes  this  difference  to  the  greater  frequency  of  urethritis  in  the 
male,  this  being  the  only  form  of  gonorrhoea,  capable,  as  he  supposes,  of 

'  Ann.  d'ocul.,  Brux.,  8c  serie,  t.  ler,  jj.  355. 


SYMPTOMS.  21T 

occasioning  gonorrhoeal  ophthalmia.  I  have  already  dissented  from  this 
opinion  of  Ricord,  and  I  believe  that  so  far  as  any  explanation  can  be 
given  of  the  difference  in  the  relative  frequency  of  its  occurrence  in  the 
two  sexes,  it  must  be  based  upon  their  different  habits. 

Symptoms Gonorrhceal  ophthalmia  may  occur  at  any  stage  of  an  at- 
tack of  gonorrhoea,  although  it  is  said  to  be  more  frequent  during  the  de- 
cline. The  urethral  or  vaginal  dischai'ge  is  doubtless  most  contagious  when 
most  purulent,  which  is  during  the  acute  stage,  but  the  short  duration  of 
tliis  stage  affords  less  opportunity  for  it  to  be  applied  to  the  eye  than  the 
longer  stage  of  decline.  At  first,  the  disease  usually  attacks  one  eye  alone. 
It  may  remain  confined  to  this  eye,  but  not  unfi-equently,  after  the  lapse 
of  a  few  days,  the  opposite  eye  becomes  implicated. 

Tlie  symptoms  of  gonorrhoeal  ophthalmia  are,  in  the  main,  identical 
with  those  of  purulent  conjuctivitis.  The  former  disease,  however,  is  more 
rajiid  in  its  development,  and  even  more  destructive  to  sight  than  the  latter. 

The  earliest  indications  of  an  attack  of  this  disease  are  an  itching  sen- 
sation just  within  or  on  the  margins  of  the  lids,  a  feeling  as  if  some  for- 
eign body  were  ii;i  the  eye,'  and  an  increase  in  the  ocular  secretions.  The 
latter  retain  at  the  outset  their  normal  trans[)arency,  although  they  appear 
unusually  viscid  ;  the  ciliai  become  adherent  and  glued  together,  and  a 
collection  of  dried  mucus  may  be  seen  at  the  inner  canthus.  As  the  dis- 
ease progresses,  the  vessels  underlying  the  conjunctiva  become  distended 
with  blood.  They  may  at  first  be  distinguished  from  each  other  as  in 
simple  conjunctivitis,  but  they  are  soon  lost  in  a  uniform  red  appearance 
of  the  globe,  extending  as  far  as  the  cornea ;  which  retains  its  normal 
transparency.  The  conjunctiva  is  also  found  to  be  somewhat  elevated 
above  the  sclerotica  by  an  effusion  of  serum,  and  its  surface  is  roughened 
by  swelling  of  its  papilla?.  Meanwhile,  the  discharge  has  become  purulent, 
and  is  secreted  abundantly  from  the  inflamed  surfaces. 

An  attack  of  gonorrha'al  ophthalmia  is  so  rapid  in  its  progress,  that  the 
early  symptoms  just  now  described  may  have  passed  away  before  the  first 
visit  of  the  surgeon,  who  is  often  called  to  see  his  patient  only  after  the 
full  development  of  the  disease.  He  probably  finds  him  sitting  up,  his 
head  bent  forwards,  his  chin  resting  on  his  breast,  and  his  handkerchief 
applied  to  his  cheek  to  absorb  the  discharge,  which  irritates  the  surface 
upon  which  it  flows.  The  eyelids  are  swollen,  especially  the  upper,  which 
slightly  overlaps  the  lower,  and  is  of  a  reddish  or  even  dusky  hue.  The 
patient  states  that  he  is  unable  to  open  the  eye.  His  inability  to  do  so 
is  caused  less  by  an  intolerance  of  light,  than  by  the  mechanical  obstruction 
which  the  swelling  of  the  lids  occasions,  and  by  tlie  pain  which  is  excited 
by  any  friction  of  the  inflamed  surfaces  upon  each  other. 

The  surgeon  now  moistens  tlie  edges  of  the  lids  with  a  rag  dipped  in 
warm  water  in  order  to  facilitate  their  separation,  and  proceeds  with  his 
examination.  In  his  attempt  to  open  the  eye,  he  is  careful  not  to  make 
pressure  u[)on  the  globe,  in  order  to  avoid  giving  unnecessary  pain,  and 
also,  lest  the  cornea,  if  already  ulcerated,  may  be  ruptured,  and  the  con- 


218 


GONORRH(EAL    OPHTHALMIA. 


tents  of  the  jrlobe  escape.  With  one  finger  placed  just  below  the  eye,  he 
slides  the  integument  downwards  over  the  malar  bone,  and  thus  everts  the 
lower  lid,  the  upper  lid  being  elevated  by  a  similar  manoeuvre  with  the 
other  finger  of  the  same  hand  applied  below  tlie  edge  of  the  orbit ;  or, 


Fisr.  46. 


Fiff.  47. 


Ophthalmic  gonorrhoea.     (Dalrymple.) 

again,  he  may  expose  the  globe  by  seizing  the  lashes  and  margin  of  the 
upper  lid  with  the  thumb  and  finger  and  drawing  the  lid  forwards  and  up- 
wards. All  this  may  be  accomplished  with  the  left  hand,  the  right  being 
left  free  to  wipe  away  the  discharge,  or  to  make  applications  to  the  eye. 

As  soon  as  the  lids  are  separated,  a  quantity  of  thick,  yellowish  pus 
wells  up  between  them  and  partially  obstructs  the  view ;  the  swollen  pal- 
pebral conjunctiva,  compressed  by  the  s[)asmodic  action  of  the  orbicularis 
muscle,  may  also  project  in  folds.  The  collection  of  matter  is  now  re- 
moved with  a  soft,  moist  sponge  or  rag,  and  the  surface  of  the  ocular  con- 
junctiva exposed.  This  membrane  is  found  to  be  of  a  uniform  red  color, 
with  the  vessels  undistinguishable  from  each  other,  and  elevated  above 
the  sclerotica  by  an  efi'usion  of  serum  and  fibrin  in  the  cellular  tissue  be- 
neath it.  This  swelling  of  the  conjunctiva  is  seen  to  terminate  at  the 
margin  of  a  central  depression  occupying  the  position  of  the  cornea,  and 
filled  with  a  collection  of  the  less  fluid  constituents  of  the  puriform  dis- 
charge, which  may  at  first  sight  be  mistaken  for  the  debris  of  a  disorgan- 
ized cornea.  On  removing  this  matter,  however,  the  latter  structure  may 
still  be  found  clear  and  transparent,  at  the  bottom  of  the  depression,  where 
it  is  overlapped  by  the  swollen  conjunctiva.  In  less  fortunate  cases,  it 
may  have  become  hazy  from  the  infiltration  of  pus  between  its  layers,  or 
ulceration  may  have  already  commenced.  If  an  ulcer  is  not  evident  on 
first  inspection,  it  may  often  be  discovered  at  the  margin  of  the  cornea  by 


SYMPTOMS.  219 

gently  pushing  to  one  side  the  overlapping  fold  of  conjunctiva.  Mean- 
while, the  secretion  of  pus  is  constantly  going  on  and  requires  repeated 
removal.  It  is  astonishing  to  observe  how  large  a  quantity  of  this  fluid 
can  be  secreted  by  so  limited  a  surface.  It  has  been  estimated  at  more 
than  three  ounces  per  day  in  some  cases. 

The  amount  of  pain,  occasioned  by  this  disease,  varies  in  different  cases. 
During  the  development  and  acme  of  the  inflammation,  it  is  generally 
severe.  It  is  described  by  the  patient  as  a  sensation  of  burning  heat  and 
tension  in  the  eyeball,  radiating  to  the  brow  and  temple.  The  system  at 
large  sym})athizes  with  the  local  disease.  For  a  time  there  may  be  general 
febrile  excitement,  but  symptoms  of  depression  soon  appear ;  the  })ulse 
becomes  rapid  and  irritable,  the  skin  cold  and  clammy,  and  the  patient 
anxious  and  nervous.  This  depression  of  the  vital  powers  is  not  invariably 
met  with,  but  is  the  most  frequent  condition  of  the  patient,  after  the  dis- 
ease has  continued  for  a  few  days ;  and  it  may  occur  even  at  an  earlier 
period  when  the  health  has  been  previously  impaired  by  any  cause. 

Notwithstanding  the  severity  of  the  symptoms,  resolution  is  still  pos- 
sible. Under  proper  care  and  treatment,  the  inflammatory  action  may 
abate,  and  the  tissues  recover  their  normal  condition,  leaving  the  eye  as 
sound  as  before  the  attack.  So  fortunate  a  result,  however,  is  more  to  be 
hoped  for  than  confidently  anticipated.  The  chances  of  success  are  greater 
when  the  case  is  seen  at  an  early  period,  before  the  effusion  beneath  the 
conjunctiva  has  been  rendered  firm  by  a  deposit  of  fibrin,  or  before  ulcera- 
tion of  the  cornea  has  commenced.  The  latter  is  the  chief  danger  to  be 
feared.  Ulceration  usually  commences  at  the  margin  of  the  cornea,  and 
may  extend  around  its  circumference,  or  advance  towards  its  centre.  It 
is  in  some  cases  superficial  ;  in  others,  it  penetrates  through  the  whole 
thickness  of  tlie  cornea,  and  prohqjse  of  the  iris  ensues,  or  more  or  less  of 
the  contents  of  the  globe  escapes.  Sometimes  a  portion  or  the  whole  of 
the  corneal  membrane  becomes  disorganized,  and  comes  away  en  masse. 
The  eye  has  been  known  to  be  destroyed  in  this  manner  within  twenty- 
four  hours  after  the  first  sym[)toms  of  the  disease  were  observed,  and  this 
catastrophe  is  said  to  have  occurred  in  a  single  night,  in  a  case  at  the  New 
York  Hospital.  The  escape  of  the  aqueous  humor,  and  other  contents  of 
the  globe,  is  usually  followed  by  an  amelioration  of  tlie  pain,  and  the 
patient  often  entertains  the  hope  that  he  is  improving,  while  the  surgeon 
knows  that  the  sight  is  irretrievably  lost. 

Tlie  amount  of  permanent  injury  inflicted  u])on  the  eye  will  depend 
upon  the  extent  and  situation  of  the  ulceration.  When  the  latter  lias  been 
superficial,  and  situated  near  the  margin  of  the  cornea,  the  resulting  opa- 
city will  not  interfere  with  vision,  and  even  when  the  leucoma  is  central, 
an  operation  for  artificial  pupil  is  still  practicable,  if  any  portion  of  the 
cornea  remain  clear.  Perforation  of  tlie  anterior  cliamber  and  prolapse 
of  tlu!  iris,  when  })artial,  may  also  be  remedied  by  art ;  l)ut  when  the 
wliole,  or  the  larger  jiortion  of  the  cornea  has  slougherl  away,  ami  the  pro- 
lapsed iris  has  become  cov(;red  with  a  dense  layer  of  fibrin,  forming  an 
extensive  stapiiyloma,  the  case  is  hopeless. 


220  GONORRHCEAL    OPHTHALMIA. 

Diagnosis Independently  of  the   history  of"  tlie  case,  we  have  no 

means  of  distinguishing  gonorrhoea!  ophthalmia  from  severe  purulent 
conjunctivitis.  It  has  been  asserted  that  the  former  commences  in  inflam- 
mation of  the  ocular  conjunctiva,  while  the  latter  first  affects  the  lining 
membrane  of  the  lids.  Even  if  this  were  true,  it  would  afford  but  little 
assistance  in  the  diagnosis,  since  we  are  rarely  enabled  to  watch  the  early 
symptoms. 

Treatment In  undertaking  the  treatment  of  a  case  of  gonorrhcnal 

ophthalmia,  it  is  of  the  first  importance  that  the  patient  be  intrusted  to  the 
care  of  an  intelligent,  careful,  and  faithful  nurse,  whose  whole  time  and 
attention  can  be  devoted  to  carrying  out  the  surgeon's  directions.  This 
disease  is  so  rapid  in  its  progress,  that  neglect  for  a  few  hours  only  may 
prove  fatal  to  vision  ;  if  the  eye  be  saved,  a  large  share  of  the  credit  will 
be  due  to  the  faithfulness  of  the  attendant.  It  hardly  need  be  said  that 
the  light  touch  and  gentle  hand  of  a  devoted  woman  should  be  secured,  if 
possible. 

The  directions  of  the  surgeon  should  vary  according  to  the  stage  of  the 
disease.  If  the  inflammation  has  commenced  within  a  few  hours  only,  and 
has  not  as  yet  attained  its  height,  from  four  to  six  leeches  may  be  applied 
near  the  external  canthus  of  the  affected  eye,  or  a  number  of  them  be 
made  to  attach  themselves  to  the  mucous  membrane  of  the  corresponding 
nostril.  If  leeches  are  not  at  hand,  cups  to  the  temples  will  suffice.  Such 
local  depletion  may' generally  be  repeated  with  benefit,  for  a  day  or  two, 
once  or  twice  in  the  twenty-four  hours,  especially  if  the  patient  be  of  full 
habit.  If,  however,  the  disease  progresses  uncliecked,  and  especially  if 
there  be  any  symptoms  of  general  depression  of  the  system,  even  this 
slight  abstraction  of  blood  should  be  avoided.  It  is  adapted  only  to  the 
early  stage  of  the  inflammation,  and,  at  a  later  period,  is  useless,  if  not 
positively  injurious. 

In  the  early  stage  of  this  aflfection,  we  often  derive  great  benefit  from 
the  constant  application  of  cold.  A  single  thickness  of  linen  or  thin  cotton 
should  be  torn  into  strips  of  convenient  size  and  shape,  and  laid  upon  or 
between  pieces  of  ice.  A¥hen  thoroughly  chilled,  one  should  be  laid  over 
the  eye,  and  be  replaced  by  a  fresh  one  every  three  to  five  minutes.  We 
would  recommend  these  applications  to  be  kept  up  during  the  whole  of  the 
first  night  followin£  the  commencement  of  the  attack.  We  can  the  next 
day  decide  on  their  continuance  or  suspension  from  the  symptoms  and  the 
effect  produced. 

If  the  inflammation  tend  to  increase,  a  free  purge  should  be  adminis- 
tered, as,  for  example,  five  grains  of  calomel  followed  by  half  an  ounce  of 
castor  oil,  a  full  dose  of  Epsom  salts,  or  three  "  compound  cathartic  pills." 
With  regard  to  the  diet  of  the  patient,  much  will  depend  upon  his  general 
condition.  As  a  general  rule  at  this  early  stage,  it  should  be  light,  con- 
sisting of  gruel,  broths,  etc. ;  at  the  same  time  it  is  important  to  recollect 
the  tendency  in  this  disease  to  depression  of  the  vital  powers,  and  to  be 
governed  by  the  indications  of  each  individual  case. 


TREATMENT.  221 

Lastly,  but  by  no  means  of  least  importance,  the  directions  -which  will 
presently  be  given  for  the  frequent  cleansing  of  the  eye,  should  be  insisted 
on,  and  the  attendant  be  duly  instructed  in  doing  it. 

Tlie  treatment  above  recommended  is  intended  for  the  early  stage  of 
gonorrha?al  ophthalmia,  before  much  chemosis,  swelling  of  the  lids,  or 
other  severe  symptoms  have  set  in.  In  most  cases,  however,  as  already 
stated,  the  surgeon  does  not  see  his  patient  till  the  disease  has  attained 
its  height,  when  some  modification  of  the  above  treatment  is  required. 

Leeches  and  cups  can  now  rarely  be  used  to  advantage.  At  the  best, 
they  will  be  impotent  to  stay  the  progress  of  the  inflammation.  Cathartics 
should  be  given  as  in  the  first  stage, ^  and  one  or  two  free  evacuations  from 
the  bowels  secured  each  day.  Hei-e  again  the  general  condition  of  the  patient 
will  in  a  measure  determine  the  diet  to  be  recommended;  but  in  the  great 
majority  of  cases  nourishment  should  be  administered  as  freely  as  the  appe- 
tite will  admit,  and  may  consist  of  bread,  milk,  beef-tea,  steaks,  mutton, 
eggs,  etc.  When  the  patient  is  unable  to  eat,  and  especially  if  his  skin  is 
found  to  be  cool  and  his  pulse  irritable,  or  again,  if  ulceration  of  the  cornea 
has  already  commenced,  we  must  resort  to  stimulants  and  tonics.  These 
are  almost  always  required  in  this  stage  of  the  disease  in  hospital  practice, 
where  patients  are  generally  more  or  less  cachectic,  and  even  in  private 
practice  the  subjects  of  gonorrhocal  ophthalmia  are  often  run  down  by  an 
irregular  course  of  life.  Nothing  will  so  much  contribute  to  hasten  de- 
structive ulceration  of  the  cornea  as  a  low  state  of  the  vital  powers.  The 
least  indication  of  this  condition  should  be  met  by  quinine,  ale,  porter, 
wine,  or  milk-punch,  freely  administered. 

Tlie  room  occupied  by  the  patient  should,  if  possible,  be  spacious,  dry, 
and  well  ventilated.  The  eyes  may  be  protected  from  a  glare  of  light  by 
the  position  of  the  patient,  or  by  a  pasteboard  shade,  or  by  curtains;  but 
the  room  should  not  be  entirely  darkened,  as  the  complete  exclusion  of 
light  favors  congestion  of  the  eye.  With  still  stronger  reason,  should  the 
eyes  be  uncovered  and  kept  free  from  poultices,  alum-curds,  tea-leaves, 
raw  oysters,  or  similar  applications,  which  are  often  recommended  by  some 
officious  acquaintance.  No  surer  way  of  destroying  the  sight  could  be 
devised  than  the  use  of  these  articles. 

When  chemosis  has  already  taken  place,  no  time  sliould  be  lost  in 
dividing  the  ocular  conjunctiva  and  the  subjacent  cellular  tissue  by  means 
of  a  scarificator,  bistoury,  or  scissors,  and  the  operation  should  be  repeated 
once  or  more  frequently  during  the  twenty-four  hours,  so  long  as  the 
chemosis  continues.  The  Lite  Mr.  Tyrrell  advised  radiated  incisions  be- 
tween tlie  courses  of  the  recti  muscles,  on  the  supposition  that  ulceration 
of  the  cornea  was  due  to  constriction  of  the  conjunctival  vessels  exercised 
by  the  chemosis,  which  it  was  desirable  to  relieve  without  cutting  off  the 
vascular  supply  by  dividing  the  larger  vessels.  Experience,  however,  has 
shown  that  his  theory  was  incorrect,  and  that  as  much  benefit  accrues  from 

'  When  the  disease  has  already  made  considerable  progress  before  the  surgeon 
is  calli'd,  an  active  cathartic,  as  croton  oil,  should  be  selected. 


222  GONORRHCEAL    OPHTHALMIA. 

simply  snipping  the  conjunctiva  and  underlying  cellular  tissue  wherever  it 
is  pulifed  up  by  infiltration,  and  promoting  the  flow  of  blood  by  the  appli- 
cation of  warm  water.  Within  half  an  hour  after  the  blood  has  ceased  to 
flow,  the  whole  inflamed  surface  should  be  freed  from  pus  and  brushed 
over  with  a  camel's-hair  pencil  dipped  in  a  solution  of  nitrate  of  silver 
containing  forty  to  sixty  grains  to  the  ounce,  or  the  solid  crayon  may  be 
applied,  taking  care  to  remove  the  residue  by  a  free  application  of  tepid 
water  afterwards. 

In  saying  that  the  "whole  inflamed  surface"  should  receive  this  appli- 
cation, we,  of  course,  include  the  palpebral  as  well  as  the  ocular  conjunc- 
tiva, and  the  former  can  only  be  reached  by  everting  both  the  upper  and 
under  lid.  Now,  if  any  difficulty  is  met  with  in  accomplishing  this  ever- 
sion,  the  palpehral  opening  should  he  enlarged  by  dividing  the  external 
canthus  ivith  a  pair  of  blnnt-pointed  scissors. 

The  "mitigated  lapis"  (crayons  of  the  nitrate  diluted  with  the  chloride 
of  silver  to  different  strengths)  is  excellent  for  these  applications.  Tlie 
inflamed  surface  is  left  covered  with  a  superficial  whitish  eschar,  and  its 
secretion  is  for  a  time  arrested.  No  further  application  need  be  made 
while  this  eschar  i-emains,  but  when  it  falls  ofl"  spontaneously  and  tlie  sur- 
face again  commences  to  suppurate,  the  application  should  be  repeated. 

Instillations  of  a  solution  of  the  nitrate,  which  were  formerly  much  in 
use,  are  not  to  be  recommended,  for  the  reason  that  they  naturally  fall  on 
the  cornea,  where  tliey  are  not  wanted  and  where  they  cause  great  pain, 
and  that  they  fail  to  reach  thoroughly  the  conjunctiva,  for  which  they  are 
intended. 

At  the  first  visit  the  attendant,  who  is  to  take  charge  of  the  case,  should 
be  instructed  as  to  her  duties,  and  the  importance  of  her  faithfully  per- 
forming them.  She  should  be  made  to  look  on  while  tlie  surgeon  goes 
through  the  process  of  opening  and  cleansing  the  eye,  and  be  taught  to 
follow  his  example.  A  syringe  is  sometimes  recommended  for  the  purpose 
of  removing  the  pus.  There  are,  however,  two  objections  to  the  employ- 
ment of  this  instrument:  in  the  first  place,  unless  used  with  gentleness, 
the  force  of  the  stream  irritates  the  inflamed  and  sensitive  conjunctiva; 
and,  afain,  the  injected  fluid,  mixed  with  contagious  matter,  may  be  re- 
flected back,  and  strike  the  eye  of  the  attendant  or  fall  upon  the  opposite 
eve  of  the  patient.  Several  cases  are  recorded  in  which  this  accident  has 
occurred.  For  these  reasons  a  soft  rag  is  to  be  preferred,  and  this,  again, 
is  better  than  a  sponge,  because  it  is  more  cleanly  and  may  be  frequently 
changed.  By  squeezing  the  fluid  from  the  rag  upon  the  adherent  portions 
of  tlie  discharge,  or  by  gently  toucliing  them  with  a  free  fold  of  the  cloth 
projecting  beyond  the  fingers,  they  can  readily  be  detached.  Simple  tepid 
water  may  be  used  for  these  ablutions,  but  I  prefer  a  solution  of  alum,  of 
the  strength  of  a  drachm  to  the  pint.  The  nurse  should  be  directed  to 
repeat  them  every  hour  or  every  half  hour,  according  to  the  severity  of 
the  case,  and  the  patient  may  be  furnished  with  a  cupful  of  the  solution 
to  bathe  the  external  surface  of  the  eye  and  wash  away  the  discharge, 
still  more  frequently.     Cleanliness  may  be  still  further  promoted  by  smear- 


TREATMENT.  223 

ing  the  edges  of  the  lids  and  cilite  with  simple  cerate,  so  as  to  prevent 
their  becoming  incrusted  with  matter. 

The  strong  solution  of  nitrate  of  silver,  already  mentioned,  may  be  re- 
applied by  the  surgeon  twice  a  day  when  he  makes  his  visits.  The  fre- 
quency, however,  of  the  application  should  depend  upon  the  condition  of 
the  parts  and  the  effect  produced.  No  routine  pi'actice  is  admissible.  The 
patient  must  not  be  deprived  of  sleep  by  too  frequent  repetition  of  these 
measures  during  the  night,  but  he  should  be  provided  with  a  watcher,  who 
will  cleanse  the  eye  and  apply  the  solution  of  nitrate  of  silver  every  few 
hours.  If  necessary,  sleep  must  be  promoted  by  the  administration  of  an 
opiate. 

The  time  has  gone  by,  when  mercurials  were  thought  requisite  in  this 
disease,  on  account  of  its  supposed  syphilitic  origin.  The  only  circum- 
stances which  can  justify  their  employment  is  the  presence  of  a  firm,  fleshy 
chemosis,  which,  owing  to  its  consistency,  cannot  be  relieved  by  incisions. 
In  such  cases,  mercurials  may  perhaps  hasten  the  absorption  of  the  fibri- 
nous deposit:  but  they  should  be  used  with  great  caution,  especially  when 
ulceration  of  the  cornea  has  already  commenced,  and  should  never  be 
pushed  to  salivation.  An  excellent  formula,  combining  the  "  gray  powder" 
with  quinine,  is  the  following: — 

I^.     Hydrarg.  cum  Creta  gr.  ij  ...     112 

Quinic'e  Sulphatis  gr.  j-iv.  .     .     .     \06 — 25 
Misce  et  ft.  pulv. 
One  to  be  taken  morning  and  night. 

When  only  one  eye  is  affected,  the  greatest  care  should  be  taken  to  avoid 
inoculation  of  the  other  by  allowing  the  discharge  to  c(mie  in  contact  with 
it.  On  the  slightest  indication  of  inflammation  in  the  latter,  a  weaker 
solution  of  nitrate  of  silver  should  be  applied  to  it,  as  frequently  as  to  the 
eye  first  affected. 

Wlien  there  is  excessive  oedema  of  the  lids,  it  may  interfere  witli  open- 
ing the  eye  and  cause  pressure  upon  the  globe ;  in  which  case  relief  may 
be  given  by  puncturing  the  skin  in  several  places  with  a  lancet.  Division 
of  the  external  canthus,  already  mentioned,  in  order  to  facilitate  the  ex- 
posure of  the  inflamed  conjunctiva,  was  first  recommended  by  Mr.  France.* 

As  the  symptoms  improve,  the  stronger  solution  of  nitrate  of  silver  may 
be  omitted,  and  the  weaker  applied  less  frequently.  When  the  chief 
danger  is  passed,  the  collyrium  may  often  be  changed  with  benefit,  and 
one  of  the  following  substituted: — 

I^.     Zinci  Sulphatis  gr  ij 0112 

(ilycerina?!  3ij lOloO 

Vini  Opii  3j 41(10 

A<iua!  3v 2U|UU 

M. 

IJ..     Addi  Galilei  gr.  x OlGO 

Glycerinje  5''j ir)|70 

Vini  Opii  3ij S  00 

Aqua;  Campliora'  q    h.  ad  §iv    .     .     .  125  00 

M. 

'  Guy's  Hospital  Reports,  third  series,  vol.  iii. 


224  GONOREHCEAL    OPHTHALMIA. 

By  fill"  the  most  convenient  way  of  applying  coUyria  to  the  eye,  either 
in  tlie  affection  under  consideration  or  in  iritis  when  instillations  of  a  solu- 
tion of  atropine  are  required,  is  by  means  of  a  very  simple  instrument,  con- 
sisting of  a  glass  tube  with  a  piece  of  closed  India-rubber  tubing  attaclied. 
Compression  of  the  India-rubber  tubing  enables  the  operator  to  take  up  a 
few  drops  of  the  Avash,  and  in  a  similar  manner  to  inject  it  into  the  eye. 
With  children  and  timid  persons  this  is  specially  of  value. 

Fig.  48. 


A  simple  iustruinent  for  applying  Jrops  to  the  eye. 

I  have  met  with  cases  in  which  a  solution  of  nitrate  of  silver  appeared 
to  irritate  the  eye,  and  in  which  the  above  collyria  were  found  preferable 
even  in  the  acute  stage  of  the  disease. 

The  occurrence  of  an  ulcer  upon  the  cornea  is  of  serious  moment,  and 
the  friends  of  the  patient  should  be  informed  of  the  danger  to  vision. 

The  pupil  should  be  dilated  by  dropping  a  solution  of  atropine  upon  the 
globe  several  times  a  day,  or  by  smearing  extract  of  belladonna,  moistened 
with  glycerine,  around  the  orbit.  The  former  is  much  more  cleanly.  The 
usual  strength  of  the  solution  employed  is  from  two  to  four  grains  to  the 
ounce.  The  object  of  thus  dilating  the  pupil  is  to  diminish  the  prolapse  of 
the  iris  if  the  ulcer  should  penetrate  through  the  cornea,  and,  if  possible, 
to  prevent  the  pupil's  becoming  involved  in  the  resulting  synechia.  The 
chances  of  accomplishing  this  are  not  very  great,  for  a  pupil  dilated  by 
mydriatics  contracts  as  soon  as  the  aqueous  humor  escapes,  as  is  seen 
durinf'  the  operation  of  extraction  for  cataract;  still  as  the  evacuation  of 
the  contents  of  the  anterior  chamber  in  perforating  ulcer  of  the  cornea  is 
often  sudden,  some  hope  may  be  entertained  of  limiting  the  prolapse.  I 
would  a"-ain  remind  the  reader  of  the  importance  of  avoiding  antiphlo- 
gistic remedies  and  of  the  necessity  of  supporting  the  strength,  when  the 
cornea,  a  tissue  of  low  vitality,  is  attacked  by  the  ulcerative  process. 
Cupping,  leeching,  low  diet,  and  mercurialization  Avill  be  sure  to  hasten 
destruction  of  the  eye,  which  can  only  be  saved,  if  saved  at  all,  by  gener- 
ous living,  stimulants,  and  tonics. 

A  o-ranular  condition  of  the  palpebral  conjunctiva  is  frequently  left  after 
an  attack  of  gonorrhoeal  ophthalmia,  and  may  keep  up  a  slight  discharge 
and  irritation  of  the  eye  for  a  considerable  time.  The  best  means  for  its 
removal  consists  in  the  application  of  a  crystal  of  sulphate  of  co[)per  to 
the  everted  lids  every  second  or  third  day ;  and  the  general  system  should, 
at  the  same  time,  be  supported. 

When  a  staphyloma  has  formed,  its  friction  against  the  lids  is  often  a 
source  of  irritation  to  the  affected  eye,  and,  through  sym|)athy,  to  its 
fellow.  If  it  is  small,  there  may  be  hope  of  its  contracting  and  being  less 
prominent,  as  the  fibrin  covering  it  becomes  more  firmly  organized;  and 
it  may  be  pencilled  over  daily  with  a  strong  solution  of  nitrate  of  silver 


TREATMENT.  225 

with  a  view  of  favoring  tliis  result.  When,  however,  it  has  ah-eady  at- 
tained considerable  size,  and  covers  so  large  a  portion  of  the  cornea  that 
there  is  no  chance  of  the  eye  serving  as  an  organ  of  vision  in  future,  it  is 
useless  to  make  any  further  attempts  to  save  the  eye,  especially  as  its  in- 
tlamed  condition  endangers  the  integrity  of  its  fellow,  and  the  intraocular 
pressure  will  probably  still  further  increase  the  size  of  the  staphyloma, 
until  it  bursts  of  itself  or  is  relieved  by  art.  Two  operations  are  available 
under  these  circumstances :  one,  the  ordinary  excision  of  the  sta[)hyloma- 
tous  projection  and  sinking  of  the  eye;  the  other,  enucleation  of  the  globe 
by  the  modern  or  Bonnet's  method. 

The  former  is  to  be  preferred,  as  a  general  rule,  in  cases  of  staphylo- 
mata  i'ollowing  gonorrheal  ophthalmia,  because  the  staphyloma  is  usually 
limited  to  the  cornea,  and  the  deeper  tissues  of  the  eye  are  commonly, 
though  not  always,  sound.  Moreover,  the  mobility  of  an  artificial  eye  ia 
greater  when  worn  upon  a  sunken  globe,  than  when  the  latter  is  removed  ; 
and,  again,  patients,  through  ignorance  of  the  simple  modern  operation 
for  extirpation,  are  very  averse  to  its  performance.  At  the  same  time,  it 
should  be  recollected  that  a  sunken  eye,  especially  when  irritated  by  wear- 
ing a  glass  substitute,  may  at  any  future  period  become  inflamed  and  en- 
danger the  integrity  of  its  fellow  through  sympathy.  After  the  removal 
of  a  staphyloma,  therefore,  patients  should  always  be  warned  of  this 
danger,  and  cautioned  to  seek  advice  at  once,  if  ever  the  stump  should 
become  inflamed,  or  the  sight  of  the  lellow  eye  should  begin  to  fail.' 

The  operation  for  removing  a  staphyloma  is  too  well  known  to  I'equire 
description  here.  There  is  only  one  point  to  which  I  desire  to  call  atten- 
tion. After  the  operation,  the  lids  should  be  closed  by  stri})S  of  isinglass 
plaster  and  remain  so  until  tiie  wound  has  entirely  healed  ;  otherwise  the 
friction  of  the  lids  and  the  exposure  of  the  hyaloid  membrane  to  the  air, 
will  be  likely  to  set  up  inflammation  in  the  deeper  tissues  of  the  eye  and 
cause  much  suftering. 

P^nucleation  of  the  globe  should  be  preferred,  when  internal  or  general 
ophthalmia  has  supervened  ;  when  the  sta[)liyloma  includes  not  only  the 
cornea  but  a  portion  of  the  sclerotica ;  or  when  hemorrhage  has  taken 
])lace  from  the  bottom  of  the  eye,  either  on  the  perforation  of  the  anterior 
chamber,  on  the  bursting  of  the  sta|)hyloma,  or  during  an  ojieration  for  its 
removal.  The  blood,  in  these  cases,  comes  chiefly  from  the  choroidal 
vessels  ;  its  flow  may  be  arrested,  but  the  clot  can  only  be  eliminated  by 
the  slow  and  tedious  process  of  suppuration,  and  it  is  better  to  remove  the 
eye  at  once. 

The  modern  operation  for  enucleation  of  the  globe  is  exceedingly  simple. 
The  ball  of  the  eye  is  alone  removed,  while  the  remaining  contents  of  the 
orbit  iu^e   left.     The  instruments  required  are  a  pair  of  toothed  forceps, 

'  Calcareous  cl(;posit  is  very  liable  to  take  i)lace  in  sunken  globes  which  have 
become  the  seat  of  chronic  inHannnation,  and  in  such  cas(!S  it  is  inipossiI)le  to  re- 
lieve the  irritation  except  by  extirpation.  I  liave  removed  the  stump  of  an  eye, 
destroyed  by  granular  conjunctivitis,  in  a  boy  aged  IG,  in  which  I  found  a  plate 
of  calcareous  matter  the  size  of  a  three-cent  piece. 
15 


226  GONORRIICEAL    OPHTHALMIA. 

blunt-pointed  straight  scissors,  and  a  strabismus  hook.  The  eye  should  be 
ke{)t  open  with  a  wire  speculum.  The  conjunctiva  and  underlying  fascia 
are  divided  close  around  the  margin  of  the  cornea,  and  the  tendons  of  the 
four  recti  muscles  hooked  up  and  severed  as  in  an  operation  for  strabismus. 
Tiie  scissors  are  then  passed  in  behind  the  globe  and  the  optic  nerve  cut 
at  its  point  of  entrance,  when  the  ball  may  readily  be  removed,  after 
dividing  the  oblique  muscles  and  any  remaining  points  of  attachment. 
Tliere  is  no  danger  of  subsequent  hemorrliage.  Tlie  lids  may  be  allowed 
to  close,  and  the  clot  which  forms  within  them  is  the  best  hemostatic  for 
such  cases.  If  the  operation  has  been  well  performed,  without  extending 
the  incisions  beyond  the  ocular  fascia,  the  wound  will  heal  with  great 
rapidity.  I  have  frequently  been  able  to  insert  an  artificial  eye  on  the 
third  or  fourth  day  after  the  operation.' 

The  remedies  recommended  in  the  preceding  pages  for  gonorrhceal  ojdi- 
thalmia  may  be  recapitulated  as  follows  :  cleanliness,  frequent  application 
of  an  astringent  solution,  nourishment,  and,  in  most  cases,  stimulants  and 
tonics,  incisions  of  the  chemosed  conjunctiva,  cathartics,  and  local  deple- 
tion. This  plan  of  treatment  differs  widely  from  the  copious  and  repeated 
venesections,  the  low  diet,  and  the  free  administration  of  mercurials  and 
tartar  emetic,  prescribed  by  nearly  all  writers  on  this  affection  until  within 
a  few  years. 

In  the  words  of  Mr.  Dixon  :  "  The  student  ought  constantly  to  bear  in 
mind  that,  although  the  disease  termed  purulent  ophthalmia  has  received 
its  name  from  that  symptom  which  readily  attracts  notice,  namely,  the  pro- 
fuse conjunctival  discharge,  the  real  source  of  danger  lies  in  the  cornea; 
and  that,  even  if  it  were  possible  so  to  drain  the  patient  of  blood  as  mate- 
rially to  lessen  or  even  wholly  arrest  the  discharge,  we  might  still  fail  to 
save  the  eye.  It  is  not  the  flow  of  pus  or  mucus,  however  abundant,  that 
should  make  us  anxious,  but  the  uncertainty  as  to  whether  the  vitality  of 
the  cornea  be  sufficient  to  resist  the  changes  which  threaten  its  transpa- 
rency. These  changes  are  twofold — rapid  ulceration  and  sloughing. 
Now,  has  any  sound  surgeon  ever  recommended  excessive  general  bleed- 
ing and  salivation  as  a  means  of  averting  these  morbid  changes  from  any 
other  part  of  the  body  except  the  eye  ?  And  if  not,  why  are  all  the  prin- 
ciples which  guide  our  treatment  of  other  organs  to  be  thrown  aside  as 
soon  as  it  attacks  the  organ  of  vision  ?" 

•  It  would  be  out  of  place  in  tins  work  to  enter  more  fully  into  the  details  of 
this  and  other  operations  which  may  be  required  after  gonorrhoeal  ophthalmia. 
For  further  particulars  with  reference  to  extirpation  of  the  globe,  the  reader  is 
referred  to  an  essay  by  Mr.  Critchett,  in  the  London  Lancet  (Am.  ed.),  Jan.  1856  ; 
also  to  papers  by  Dr.  C.  R.  Agnew  and  by  the  author,  in  the  N.  Y.  Journal  of 
Med.,  Jan.  and  May,  1859. 


GONORRHCEAL    RHEUMATISM.  227 


CHAPTER   XXL 

GONORRHCEAL   RHEUMATISM. 

The  question,  Who  was  the  first  discoverer  of  a  relationship  between 
gonorrhoea  and  rheumatism?  is  not  of  much  importance,  but  has  attracted 
considerable  attention.  The  first  mention  of  such  connection,  that  I  am 
aware  of,  is  to  be  found  in  the  "Antonii  Storck  Libellus,  quo  demon- 
stratur,"  etc.  etc.,  yienna3,  1769.  Swediaur  (1781)  described  this  afi'ec- 
tion  under  the  name  of  "  Arthrocele,  Gonocele,  or  Blennorrhagic  Swelling 
of  the  Knee."^  Hunter,*  in  1786,  said:  "I  knew  one  gentleman  who 
never  had  a  gonorrhcea  but  that  he  was  immediately  seized  universally 
with  rheumatic  pains;  this  had  happened  to  him  several  times.  The  blood 
at  such  times  is  generally  free  from  the  inflammatory  appearance,  and 
therefore  we  may  suppose  that  the  constitution  is  but  little  affected." 
Since  that  time,  this  disease  has  received  particular  attention  from  various 
Avriters  on  venereal  diseases  and  diseases  of  the  joints,  among  whom  Sir 
Benjamin  Brodie,'  Sir  Astley  Cooper,*  Ricord,"  Bonnet,  of  Lyon,®  Foucart,^ 
Brandes,^  Rollet,^  and  Fournier,'"  are  especially  worthy  of  mention.  It  has 
been  the  sul)ject  of  lively  discussion  at  the  meetings  of  many  learned  socie- 
ties, and  notably  before  the  Soc.  med.  des  hopitaux  de  Paris,  in  1866,  a  full 
account  of  which  may  be  found  in  the  Gaz.  hebdomaddire  and  the  Union 
medicale  for  1866  and  1867.  It  has  by  no  means  been  allowed  to  retain 
its  place  in  the  nosological  system  undisturbed,  and  there  have  been  many 
who  have  attenqjted  to  explain  it  away,  on  various  hypotheses.  Its  claims 
to  be  considered  a  distinct  complication  of  gonorrhoea  will  appear  in  the 
course  of  this  chapter. 

To  an  observer  who  had  never  heard  of  the  connection  between  gonor- 
rhoea and  rheumatism,  it  might  indeed  ai)pear  a  mere  coincidence,  if  a 

'  A  Conipk'te  Treatise  on  the  Symptoms,  etc.,  of  Syphilis,  by  F.  Swediaur,  M.D. 
Translated  from  tlie  fourth  French  edition,  by  Thomas  T.  Ilewson.  Phila.,  1815, 
p.  108. 

*  Ricord  and  Hunter  on  Ventireal,  Bumstead's  2d  ed.,  p.  88. 

'  Brodie's  Select  Surgical  Works  :  Diseases  of  the  .Joints.     Phila.,  1847. 

*  Lectures  on  the  Principles  and  Practice  of  Surgery.     London,  183r>,  p.  482. 
5  Not^s  to  Hunter,  2d  ed.     Phila.,  1859,  p.  275. 

8  Traitedes  maladies  articulaires.     Paris,  1853,  t.  i,  \>.  37(). 

1  Quelques  considerations  pourservir  ^  I'histoire  de  I'artlirite  l)lenn(jrrhagiqiie  ; 
in  8vo.,  pp.  45.     Bordeaux,  1846. 

8  Arch.  gen.  de  med.,  Sept.,  1854. 

s  Annuaire  de  la  syphilis  ;  ann^e  1858,  Lyon. 

'0  Union  med.,  Paris,  Nos.  9  and  10,  1867  ;  also  N.  Dict.de  med.  et  de  chir.  prat.', 
Paris,  tome  v,  p.  224. 


223  GONORRIIGEAL    RHEUMATISM. 

[latient  siiflfering  from  gonorrluca  should  suddenly  be  seized  with  inflamma- 
tion of  tlie  joints;  but  should  tliis  same  patient,  after  entirely  recovering 
from  both  affections,  and  after  several  years  of  perfect  health,  again  con- 
tract gonorrhoea,  and  again  be  seized  with  articular  rheumatism,  the  occur- 
rence would  be  sufficiently  remarkable  to  excite  r.  suspicion  in  the  mind 
of  the  most  careless  observer  that  there  was  some  connection  between  the 
two.  Let  this  second  attack  be  followed  by  a  third,  fourth,  and  fifth,  and 
the  suspicion  would  be  converted  into  a  very  strong  probability.  Suppose 
that  numerous  other  patients  were  met  with  in  whom  these  two  affections 
thus  repeatedly  coexisted,  an  attack  of  gonorrha^a  in  each  of  them  being 
followed  by  one  of  rheumatism,  with  such  certainty  that  the  latter  might 
be  predicted  immediately  on  the  api)earance  of  the  former,  and  a  manifest 
relation  between  the  two  diseases  could  no  longer  be  doubted.  Now,  this 
repetition  of  these  two  diseases  in  the  same  person  is  not  merely  hypo- 
thetical— it  is  a  reality;  and  it  is  observed  in  subjects  entirely  free  from 
any  rheumatic  diathesis,  who  have  inflammation  of  the  joints  at  no  other 
time  than  when  they  have  gonorrhoea.  Among  the  many  cases  which 
mi'i'ht  be  cited,  none  perhaps  will  better  illustrate  this  [)oint  than  the  fol- 
lowing, which  I  quote  from  the  lectui-es  of  Sir  Astley  Cooper: — 

"I  wull  give  you,"  says  this  distinguished  surgeon,  "the  history  of  the 
first  case  1  ever  met  with;  it  made  a  strong  impression  on  my  mind.  An 
American  gentleman  came  to  me  with  a  gonorrhoea,  and  after  he  had  told 
me  his  story,  I  smiled,  and  said  :  do  so  and  so  (particularizing  the  treat- 
ment), and  that  he  would  soon  be  better;  but  the  gentleman  stopped  me, 
and  said,  'Not  so  fast,  sir;  a  gonorrhoea  with  me  is  not  to  be  made  so 
lirrht  of — it  is  no  trifle;  for,  in  a  short  time  you  will  find  me  with  inflam- 
mation of  the  eyes,  and  in  a  few  days,  I  shall  have  rheumatism  in  the 
joints;  I  do  not  say  this  from  the  experience  of  one  gonorrhoea  only,  but 
from  that  of  two,  and  on  each  occasion  I  was  affected  in  the  same  manner.' 
I  be""""ed  him  to  be  careful  to  prevent  any  gonorrhoeal  matter  coming  in  con- 
tact with  the  eyes,  which  he  said  he  would.  Three  days  after  this  I  called 
on  him,  and  he  said,  '  Now  you  may  observe  what  I  told  you  a  day  or  two 
a"0  is  true.'  He  had  a  green  shade  on  and  had  ophthalmia  in  each  eye ; 
I  desired  him  to  keep  in  a  dark  room,  to  take  active  aperients,  and  a]»ply 
leeches  to  the  temples.  In  three  days  more  he  sent  for  me,  rather  earlier 
than  usual,  for  a  pain  in  one  of  his  knees;  it  was  stiflT  and  inflamed  ;  I 
ordered  some  applications,  and  soon  after  the  other  knee  became  inflamcHl 
in  a  similar  manner.  The  ophthalmia  was  with  great  difficulty  cured,  and 
the  rheumatism  continued  many  weeks  afterwards." 

Similar  cases  are  related  by  nearly  every  author  who  has  written  on  this 
affection,  and,  further  on,  many  are  given  in  a  table  of  the  diseases  of  the 
eye  which  accompany  gonorrhoeal  rheumatism.  M.  Rollet  relates  in  detail 
five  such  instances  occurring  in  his  own  |)ractice,  and  this  repetition  took 
place  in  eight  of  thirty-four  cases  reported  by  Brandes,  of  Copenhagen, 
and  in  three  of  eight  cases  observed  by  M.  Diday.  According  to  Rollet's 
researches,  this  repetition  has  been  noted  in  nearly  one-quarter  of  the  total 
number  of  cases  of  gonorrhoeal  rheumatism  which  have  been  published. 


CAUSES.  229 

The  frequency  of  eases  like  these  can  leave  no  doubt  in  the  mind  that 
a  close  relation  exists  between  these  two  affections,  and  additional  evidence 
is  found  in  tiie  fact  that  the  rheumatism  attendant  upon  gonorrhoea  pre- 
sents certain  peculiarities,  which,  in  general,  are  sufficient  to  distinguish 
it  from  the  oi'dinary  forms  of  rheumatism. 

Causes In  comparison  with  the  great  frequency  of  gonorrhoea,  gonor- 
rhoea! rheumatism  is  exceedingly  rare.  Very  little  is  known  of  the  causes 
which  occasion  it  in  the  few,  while  the  many  affected  with  gonorrhoea  es- 
cape. Its  occurrence  might  naturally  be  attributed  to  a  rheumatic  dia- 
thesis, especially  as  the  fact  is  well  established  that  persons  subject  to 
rheumatism  are  particularly  prone  to  contract  gonorrhoea ;  and  it  is  dis- 
tinctly asserted  by  several  writers  that  a  constitutional  tendency  to  rheu- 
matism is  a  predisposing  cause  of  inflammation  of  the  joints  during  an 
attack  of  gonorrhoea.  There  is  reason  to  believe,  however,  that  the  plau- 
sibility of  this  ojjinion,  founded  on  a  priori  reasoning,  has  given  it  greater 
weigiit  than  it  deserves.  Those  who  have  expressed  it,  have  failed  to 
produce  any  evidence  in  its  support ;  and  if  we  examine  the  published 
cases  of  tiiis  disease,  we  frecpiently  tind  it  noted  that  the  jiatient  never 
suffered  from  rheumatism  excej)t  when  he  had  gonorrhcea.  M.  Rollet  has 
made  this  jjoint  a  special  subject  of  inquiry,  and  states  that  in  the  great 
majority  of  cases  of  gonorrhoeal  rheumatism  which  have  come  under  his 
observation,  there  was  no  rheumatic  diathesis  either  in  the  |  atients  or  in 
their  parents.  He  also  states  tiiat  he  has  had  under  treatment  many  pa 
tients  with  gonorrhoea  who  were  predisposed  to  rheumatism,  and  yet  in 
them,  urethritis  has  not  been  attended  by  any  inflammation  of  the  joints  ; 
and  this  fact  derives  additional  weight  from  the  frequency  with  which 
gonorrlneal  rheumatism,  after  having  once  occurred,  is  re-excited  by  a 
subsequent  clap.  These  statements  of  M.  Rollet  go  far  to  s1k»w  that  a 
rheumatic  diathesis  has  no  part  in  tlie  production  of  gonorrliu'al  rheuma- 
tism ;  and  the  contrary  opinion  is  now  generally  abandoned.^ 

In  earlier  times,  when  gonorriura  was  regarded  as  identical  with  syphi- 
lis, an  evident  explanation  of  tiie  occurrence  of  rheumatism  in  the  course 
of  a  urethritis  was  readily  found,  but  the  same  is  untenable  with  our  present 
knowledge.  The  same  is  true  of  the  "gonorrhoeal  diathesis,"  which  some 
authors  have  maintained  to  exist,  since  gonorrhoea  is  a  local  disease,  and 
docs  not  attect  tlie  system  at  large. 

It  should  be  observed  thjit  this  form  of  rheumatism  does  not  accompany 
inflammation  of  all  portions  of  the  genital  organs,  but  only  that  of  (he 
urethra.      No  attack  of  balanitis  in  the  male,  or  of  vulvitis  or  vaginitis  in 

'  \r.  Kollct  woaki'iis  his  position  by  aasHrting  an  antagonism  between  a  rheu- 
matic diathesis  and  gonorrlm'a,  in  virtue  of  which,  he  believes  that  a  clap  some- 
times cures  a  patient  of  a  tend<nicy  to  rheumatism,  from  wliich  he  lias  ])revioiisly 
suffered  for  years  !  lie  says  that  he  has  observed  one  such  case,  and  quotes  an- 
other in  detail  which  occurred  in  the  practice  of  M.  Diday  :  but  surely  it  is  more 
reasonable  to  sup])ose  that  the  disappearance  of  the  rheumatism  in  tliese  two  cases 
was  a  mere  coincidence. 


230  GONORRHCEAL    RHEUxM ATISM. 

the  female,  lias  ever  been  known  to  he  attended  by  it.  It  appears  only 
in  cases  of  urethritis.  Hence  the  ini[)ropriety  of  the  name  "  genital  rheu- 
matism" given  to  it  by  Lorain  ;  and  hence  also  (perhaps)  its  rarity  in 
women  whose  attacks  of  gonorrho'a  are  usually  limited  to  the  vagina  and 
vulva. 

It  may  be  remarked  en  passant,  that  the  most  appropriate  name  for  this 
affection  is  that  applied  to  it  by  Fournier,  viz.,  "  urethral  rheumatism" 
since  it  is  not  necessarily  connected  with  gonorrhu-a,  but  maybe  produced 
by  the  simple  passage  of  a  sound  or  other  cause  of  uretliral  irritation. 

Tiie  idea,  advanced  by  some  authors,  that  urethral  rheumatism  is  due 
to  a  mild  form  of  purulent  infection,  is  a  mere  supposition,  unsupported 
by  any  evidence.  In  short,  the  mode  of  connection  between  the  disease 
of  the  joints  and  the  urethritis  is  at  present  entirely  unknown. 

The  exciting  cause  of  gonorrhoial  rheumatism  cannot  be  found  in  the 
use  of  copaiba  and  cubebs,  as  has  been  sometimes  asserted,  or  in  exposure 
to  cold  and  sudden  changes  of  temperature.  Inflammation  of  the  joints 
has  frequently  been  known  to  occur  in  patients  wlio  have  taken  neither  of 
these  drugs,  and  who  have  been  confined  to  the  wards  of  a  hospital  during 
the  whole  course  of  their  attack  of  gonorrhoea.  On  the  other  hand,  how 
frequently  are  copaiba  and  cubebs  administered  for  gonorrhcea,  and  how 
often  must  the  su])jects  of  clap  be  exposed  to  cold  and  moisture,  and  yet 
how  rare  is  gonorrho>al  rheumatism  ! 

The  phenomena  of  gonorrhoeal  rheumatism  are  also  inconsistent  Avith 
the  idea  of  a  metastasis  from  the  urethra  to  the  joints,  since  in  most  eases 
there  is  an  exacerbation  of  the  urethral  discharge  preceding  the  articular 
inflammation.  This  is  especially  noticeable  in  chronic  cases  of  gleet,  in 
which  gonorrhoeal  rheumatism  supervenes. 

Gonorrhoeal  rheumatism  is  comparatively  rare  in  women,  indeed,  its 
existence  in  this  sex  was  formerly  denied.  Further  observation  has,  how- 
ever, shown  that  women  are  not  exem[)t  from  it,  and  no  small  number  of 
cases  liave  been  reported  by  various  authors,  as  Ili(;ord,  Vidal,  Cullerier, 
de  Meric,'  Mr.  Hardy ,'^  Dr.  Angelo  Scarenzio,^  Langlebert,*  and  Four- 
nier. The  last  named  author  saw^  seven  cases  in  women  within  about  two 
years'  time. 

Frequency This  is  a  rare  affection  if  compared  with  the  frequency 

of  gonorrhoea.  Thus  Fournier  states  that  in  1912  cases  of  gonorrhoRa 
which  have  come  under  his  observation,  he  has  met  with  31  cases  of  rheu- 
matism, or  about  one  in  62  cases;  but,  as  Fournier  remarks,  this  propor- 
tion must  be  above  the  truth,  when  we  consider  what  a  large  number 
of  cases  of  gonorrhtea  are  neglected  or  treated  by  the  patients  themselves 
without  surgical  advice. 

1  British  Med.  Journ.,  1867,  vol.  ii,  p.  33.5. 

2  Dublin  Quart.  Journ.,  vol.  xlvi,  p.  241. 

3  Giornale  Italiano,  Miiiano,  1874,  vol.  ii,  p.  129. 
<  Gaz.  m6d.  de  Lyon,  1805,  p.  484. 


SEAT. 


231 


Seat None  of  the  joints  are  exempt  from  an  attack  of  gonorrha'ul 

rheumatism,  but  this  disease  affects  the  knee  far  more  frequently  than  any- 
other  joint.  The  following  table  exhibits  the  order  of  frequency  with 
which  the  various  joints  were  affected  in  81  cases  observed  by  MM.  Fou- 
cart,  Brandes,  and  RoUet : — 


Articulation  of  the  knee 
"  "       ankle 


hips 

fingers  and  toes    . 

shoulder 

wrist    . 

elbow  . 

sternum  and  clavicle 

tarsal  bones 

sacrum  and  ilium 

lower  jaw     . 

tibia  and  fibula     . 


Fournier  gives  the  following  table  of  his  observations  : — 

Synovial  membranes  of  the  joints      .... 

"  "  "         tendons  .... 

Muscles       ......... 

The  bursje  ......... 

The  sciatic  nerv^e         ....... 


64 

30 

15 

15 

10 

10 

8 

3 

2 

2 

1 

1 

161 


51 

10 

10 

6 

5 


And  nine  cases  in  which  it  was  impossible  to  determine  the  exact  seat  of 
the  pain  complained  of  by  the  patients. 

Besides  the  joints,  gonoiThfeal  rheumatism  frequently  affects  the  ocular 
tunics;  also  the  bursas  connected  with  the  muscular  tendons,  especially  the 
tendo-Achillis ;  and  sometimes  the  sheaths  of  the  muscles,  as  in  muscular 
rheumatism.  Again,  liicord  states  that  he  has  met  with  several  patients 
who  suffered  from  severe  pain  in  the  plantar  region,  apparently  seated  in 
the  fascia?.  Dr.  Lieberinann^  rejwrts  a  case  of  suj)|)osed  gonorrhoeal  rheu- 
matic inflammation  of  the  crico-arytenoid  joint  of  the  larynx. 

The  knee-joint,  therefore,  is  the  favorite  seat  of  gonorrhoeal  rheumatism, 
though  all  the  joints  of  the  body  are  liable  to  its  attacks.  This  disease, 
however,  is  less  prone  to  cliange  its  seat  from  one  joint  to  another  than 
ordinary  artictdar  rheumatism.  This  fact  is  evident  from  an  exainination 
of  the  above  table,  which  shows  that  there  were  but  IGl  joints  atiected  in 
81  cases;  an  average  of  about  two  joints  to  each  case.  I  know  of  no 
similar  table  exhibiting  the  number  of  articulations  affecftnl  in  a  given 
number  of  cases  of  ordinary  rlieumatism,  but  the  proportion  is  undoubtedly 
much  greater.  Again,  in  10  of  tiie  11)  cases  in  the  above  table,  furnished 
by  M.  Foucart,  only  one  joint  was  affected  ;  of  the  34  cases  of  jM.  Brandes's, 
the  rheumatism  was  mono-articular  in  5,  and  also  in  10  of  the  28  cases 


>  Med.-Chir.  Centralblatt,  No.  41,  1874,  as  quoted  in  the  N.  Y.  Med.  Jour. 
Sept.,  1878,  p.  327. 


232  GONORRHffiAL    RHEUMATISM. 

collected  by  M.  Rollet.  These  facts,  therefore,  would  give  us  a  ratio  of 
about  one-third,  in  which  gonorrhoeal  rheumatism  attacks  but  a  single 
joint,  but  more  extended  statistics  are  required  before  this  proportion  is 
received  as  accurate. 

Even  when  gonorrhrcal  rheumatism  does  not  remain  confined  to  one 
joint,  but  extends  to  others,  the  articulation  first  affected  does  not  recover 
its  normal  condition,  as  it  often  does  in  ordinary  articular  rheumatism, 
but  generally  continues  in  a  state  of  inflammation  after  the  disease  is 
lighted  up  in  other  joints.  In  this  respect,  gonorrhocal  rheumatism  again 
differs  from  acute  rheumatism,  but  approximates  to  the  character  of  rheu- 
matic gout. 

There  can  be  no  question,  I  think,  that  gonorrhfjeal  rheumatism  some- 
times attacks  the  heart,  but  it  is  equally  certain  that  this  complication  is 
much  less  fretiuently  met  with  than  in  ordinary  acute  articular  rheuma- 
tism.^ Ricord  states  that  in  several  clearly  marked  cases  of  gonorrhocal 
rheumatism,  he  has  observed  symptoms  of  endocarditis,  and  also  of  effusion 
within  the  pericardium,  but  it  is  to  be  regretted  that  he  has  not  given 
these  cases  in  detail.  The  rarity  of  any  mention  of  heart  disease,  how- 
ever, in  the  reported  cases  of  gonorrhceal  rheumatism,  proves  the  correct- 
ness of  the  above  assertion  that  this  disease  is  usually  free  from  such 
complication.      The  following  case  is  reported  by  Mr.  Brandes  : — 

A  man,  50  years  of  age,  had  had  five  attacks  of  gonorrhoea  within  ten 
years ;  each  attack  being  attended  with  disease  of  the  joints.  In  a  sixth 
attack  he  was  seized  with  violent  pain  and  swelling  of  several  joints,  espe- 
cially the  knee.  A  few  days  after,  inflammation  of  the  eye  and  pericardium 
ensued.  The  friction  sound  was  well  marked;  and  the  pulsations  of  the 
heart  were  irregular.  There  was  dulness  on  percussion  over  a  considerable 
space,  with  palpitation  and  pain  in  the  precordial  region.  The  symptoms 
improved  under  venesection  and  mercurials.  Meanwhile  the  iris  became 
inflamed  in  the  right  eye,  and  a  week  after  this  eye  recovered,  the  left  was 
attacked.  The  patient  finally  recovered,  but  suffered  from  weakness  of 
the  lower  extremities  for  a  long  time,  so  that  he  was  obliged  to  walk  with 
crutches  for  several  months. 

Dr.  Marty  re|)orts  a  case  of  gonorrha3a  in  a  niivn  22  years  of  age,  which 
was  comi)licated  by  acute  endocarditis  located  at  the  aortic  valves.  There 
was  no  rheumatism  or  metastatic  articular  afl'ection.  He  has  collected 
jiine  other  cases  in  which  a  disease  of  the  heart  or  pericardium  developed 
itself  four  or  five  weeks  after  the  commencement  of  a  gonorrhoea.  Of  the 
ten  (including  the  above),  seven  were  endocarditis  and  three  pericarditis. 
In  eight  of  the  cases  the  cardiac  affliction  was  preceded  by  gonorrhfjeal 
rheumatism  ;  in  the  other  two,  there  was  none.  The  urethral  discharge 
was  re-established  when  the  acute  symptoms  disappeared.  Dr.  Marty 
concludes  that  any  serous  membrane  maybe  attacked  during  the  existence 

'   "I  am  induced  to  think  that,  under  ordinary  circumstances,  some  heart  affec 
tion  arises  in  about  half  of  all  cases  of  acute  rheumatism."   {Fuller  on  RheumiUism.) 


SYMPTOMS.  233 

of  gonorrhoea,  and  that  this  inflammation  is  due  to  the  disease  of  the 
urethra.   {Med.  Record.  Aug.  11,  1877,  from  the  Archives  gen.) 

M.  Desnos^  read  a  case  of  tliis  atfection  before  the  Paris  Hospital  Society. 
At  the  antoj)sy  a  small  ulcer  was  found  on  the  mitral  valve,  together  witli 
a  considerable  vegetant  endocarditis  of  the  aortic  valves  and  the  whole  of 
the  interior  of  the  heart. 

Ricord  is  the  only  authority,  so  far  as  I  am  aware,  who  has  seen  any 
affection  of  the  nervous  centres  in  gonorrhceal  rheumatism.  This  surgeon 
states  that  he  has  met  with  symptoms  of  compression  of  the  spinal  marrow 
and  of  the  brain,  such  as  paraplegia  and  hemiplegia,  which  appeared  to  be 
produced  by  increased  effusion  Avitliin  the  serous  membranes  of  the  brain 
and  spine,  and  which  followed  the  same  course  as  the  affection  of  the 
joints. 

No  affection  of  the  lungs  or  pleura  has  ever  been  observed  in  gonor- 
rhceal rheumatism. 

Gonorrhceal  rheumatism  is  essentially  an  hydrarthrosis,  and  in  many 
instances  the  inflammation  is  confined  to  the  synovial  membrane  of  the 
joint  during  the  whole  course  of  the  affection.  The  predilection  of  this 
disease  for  serous  membranes  is  shown  by  its  attacking  the  bursa?  con- 
nected with  the  tendons,  especially  about  the  wrist  and  ankle.  Rollet 
states  that  he  has  seen  one  case  in  which  the  seat  of  the  disease  appeared 
to  be  a  bursa  accidentally  develo|)ed  over  the  acromion  process,  and  CuUe- 
rier  has  met  with  the  same  in  the  bursa  in  front  of  the  patella. 

Symptoms In  describing  the  symptoms  of  gonorrhceal  rheumatism,  it 

is  desirable  to  take  those  of  ordinary  articular  rheumatism  as  a  standard  of 
comparison.  Proceeding  in  this  manner,  we  find  that  gonorrha-al  rheuma- 
tism is  generally  ushered  in  with  less  febrile  disturbance  than  its  more 
frequent  congener.  In  some  cases  there  is  an  entire  absence  of  premoni- 
tory symptoms,  and  the  patient's  attention  is  not  attracted  to  the  joints 
until  effusion  has  taken  place  and  motion  has  thereby  been  rendered  pain- 
ful and  difficult.  In  other  instances,  a  slight  chill  and  wandering  pains 
have  been  experienced,  before  the  morbid  action  has  become  settled  in  any 
one  joint  ;  and  those  cases  are  exceptional  in  which  the  inflammatory 
symptoms  at  the  outset  are  comparable  in  violence  to  those  of  acute  rheu- 
matism. 

AVlien  the  articular  disease  is  fairly  established,  the  pain  is  increased 
and  is  often  severe  ;  but  here,  also,  we  And  the  symptoms  less  acute,  as  a 
general  rule,  than  in  ordinary  rheumatism.  Even  in  those  cases  in  which 
the  local  pain  is  great,  there  is  much  less  general  febrile  excitement;  and 
an  examination  of  the  blood  drawn  in  five  cases  by  M.  Kollet  and  in  one 
by  M".  Foucart,  faih^d  to  show  that  bufled  and  cupped  condition  of  the 
clot  which  is  so  frequently  met  with  in  acute  rheumatism. 

Sweating,  which  is  so  abundant  in  ordinary  rheumatism,  is  absent  in  the 
form  of  the  disease  accompanying  gonorrhoea. 

'  Gaz.  licbd  ,  Paris,  Nov.  IG,  1877,  quoted  in  the  Monthly  Abstract  of  Med.  Sei., 
vol.  V,  p.  23. 


234  GONORRHCEAL    RHEUMATISM. 

The  integument  covering  the  affected  joint  generally  retains  its  normal 
color  though  it  sometimes  puts  on  the  blush  of  inflammation.  When  the 
knee-joint  is  the  seat  of  the  disease,  as  is  frequently  the  case,  the  symp- 
toms of  a  serous  effusion  within  the  capsule  are  readily  detected.  The 
patella  is  elevated  above  the  femur  and  is  freely  movable;  the  joint  has  the 
form  of  a  cube,  the  usual  depression  on  either  side  of  the  patella  being 
replaced  by  swellings,  and  fluctuation  can  be  detected  witliout  dilliculty. 
It  is  evident  that  the  inflammatory  process  is  conflned  to  the  synovial 
membrane,  and  that  the  fibrous  and  osseous  tissues  are  unaffected.  Tlie 
collection  of  serum  necessarily  impairs  the  mobility  of  the  joint,  and  pain 
is  excited  by  pressure  or  by  any  attempt  at  motion.  If  the  disease  do  not 
yield  readily  to  treatment,  other  tissues  about  the  joint  become  involved, 
and  we  may  then  find  redness  of  the  skin,  together  with  fulness  of  tlie  ves- 
sels and  a  corresponding  increase  of  the  pain  and  general  febrile  disturb- 
ance, assimilating  the  case  to  one  of  acute  rlieumatism. 

Those  cases  of  gonorrhoeal  rheumatism  which  commence  with  the  most 
decided  inflammatory  symptoms  are  generally  tlie  most  amenable  to  treat- 
ment; those,  on  the  contrary,  in  which  the  febrile  action  is  but  slight,  and 
in  which  there  is  but  little  moi-e  than  a  passive  effusion  into  the  synovial 
sac,  are  more  obstinate. 

Recovery,  in  any  case  of  this  disease,  can  rarely  be  expected  in  less  than 
a  month  or  six  weeks,  and  is  often  delayed  for  several  months  or  even 
years,  especially  when  the  patient  is  debilitated  and  when  the  affection  of 
the  urethra  is  allowed  to  run  on  or  does  not  yield  to  treatment. 

Fourniei-'  has  called  attention  to  an  interesting  and  comparatively  rare 
symptom  of  gonorrhoeal  rheumatism,  viz.,  sciatica.  He  states  tliat  he  has 
observed  seven  instances,  and  that  an  eighth  is  reported  by  Tixier.'' 

It  is  unnecessary  to  describe  the  symptoms  of  the  cardiac  affection  which 
sometimes  complicates  a  case  of  gonorrhuoal  rheumatism,  since  these  do 
not  differ  from  those  of  endocarditis  and  pericarditis  attendant  upon  ordi- 
nary acute  rheumatism.  The  inflammation  of  the  eye  which  frequently 
precedes  or  accompanies — or  sometimes  alternates  with  the  disease  of  the 
joints,  and  which  is  evidently  dependent  upon  the  same  condition  of  the 
general  system,  will  presently  receive  special  mention. 

Most  cases  of  gonorrhfcal  rheumatism  terminate  sooner  or  later  incom- 
plete resolution,  although  they  may  render  the  patient  a  cripple  for  a  long 
period.  Suppuration  within  the  bursa  very  rarely  occurs.  It  is  admitted 
by  Ricord,  who  says,  however,  that  it  is  always  due  to  some  accessory 
cause  of  inflammation  ;  and  Vidal  mentions  one  case  occurring  under  liis 
charge  in  which  it  was  necessary  to  open  the  joint  and  evacuate  tiie  puru- 
lent collection.  Zeissl  mentions  an  interesting  case  communicated  to  him 
by  Dr.  Eisenmann  in  which  death  ensued.  Again  Dr.  Prichard^  reports 
two  cases,  in  one  of  which  an  abscess  communicating  with  the  joint  formed 

'  Note  pour  servir  a  I'liistoire  du  rhumatisme  urethral,  Paris,  1866. 
*  Thfese,  considerations  sur  les  accidents  a  forme  rhuinatismale  de  la  blennor- 
rhagie.     Paris,  1866. 

3  British  Medical  Jour.,  Apr.  6,  1867. 


SYMPTOMS.  235 

on  the  thigh  just  above  the  knee,  and  another  in  the  popliteal  space.  Am- 
putation of  the  thigh  was  resorted  to,  and  an  examination  of  the  joint 
showed  extensive  ulceration  of  the  cartilages,  with  marked  increase  of  vas- 
cularity of  the  neighboring  parts.  Anchylosis,  especially  of  the  smaller 
joints,  is  a  more  frequent  termination  of  gonorrha^al  rheumatism,  and  in 
scrofulous  subjects,  this  disease  has  not  unfrequently  been  followed  by  that 
strumous  affection  of  the  joints  known  as  '•  Avhite  swelling;"  here,  as  in 
other  well-known  instances,  a  constitutional  cachexia  selects  the  weakest 
part  of  the  body  as  the  seat  of  its  manifestation. 

Dr.  Holscher^  reports  a  case  in  wliich  death  is  said  to  have  occurred 
from  gonorrhccal  rheumatism.  An  abscess  formed  in  the  affected  joint, 
and  purulent  infection  ensued,  terminating  fatally. 

The  period  at  which  rheumatism  makes  its  appearance  in  the  course  of 
gonorrhoea  appears  to  be  more  variable  than  that  of  epididymitis.  Some 
cases  are  met  with  in  which  the  affection  of  the  joints  occurs  during  the 
acute  stage,  or  first  week  or  two  of  the  duration  of  the  clap  ;  indeed  it 
may  occur  coincidenfally  with,  or  even  before  the  appearance  of  any  dis- 
charge from  the  urethia,  and  it  is  worthy  of  notice  that  such  eaily  cases 
are  generally  more  acute  in  their  character  than  later  ones.  Yet  in  the 
majority  of  cases  we  find  that  the  rheumatism  manifests  itself  at  a  later 
period,  when  the  urethral  discharge  has  passed  its  climax.  Generally, 
we  find  that  the  running  has  been  more  copious  for  a  few  days  preceding 
the  outbreak  of  the  rheumatism,  and  this  is  especially  noticeable  in  long- 
standing cases  of  clap  which  have  been  accompanied  by  several  repetitions 
of  the  articular  aff^ection,  each  of  which  has  followed  an  exacerbation  of 
the  discharge.  Cases  in  which  the  running  suddenly  diminishes  or 
entirely  dries  up  before  the  rheumatism  appears,  must  be  regarded — in 
spite  of  the  opposite  opinion  so  frequently  expressed — as  rare  and  excep- 
tional, and  not  sufficient  for  the  basis  oi"  a  theory  of  metastasis.  In  de- 
ciding this  point — to  which  much  importance  has  been  attached — it  should 
be  recollected  that  if  the  rheumatism  occurs  several  weeks  after  contagion, 
the  discharge  will  jorobably  have  somewhat  diminished,  following  the 
course  which  it  usually  pursues  in  cases  entirely  free  from  any  comjdica- 
tion.  After  the  disease  of  the  joints  is  established,  the  running  sensibly 
decreases  in  most  cases,  as  a  conse(iuence  of  revulsive  action.  In  other 
instances — estimated  by  Rollet  at  abo\it  one-tliird — it  remains  without 
mucli  change.  It  rarely  disappears  entirely,  except  as  the  result  of  treat- 
ment. 

Gonorrhccal  rheumatism,  unlike  acute  rheumatism,  but  lik(i  rlieumatic 
gout,  fre(iuently  attacks  the  eye.'^     The  ocular  affection  in  these  cases,  is 

'  A.nialos  de  Holschor,  1844. 

2  "  In  true  rheumatism,  tlit)  (»yo  seldom  suffers  ;  so  seldom,  that  I  find  no  record 
of  any  aflfection  of  that  organ  in  more  tlian  4  f>nt  of  the  379  cases  of  acute  and  sub- 
acntc!  rheumatism  admitted  into  St.  George's  Hospital,  during  the  time  I  ludd  the 
office  of  Medical  Registrar.  Hut  in  rheumatic  gout,  the  eye  is  not  unfrequently 
implicated.  It  was  inflamed  in  11  out  of  the  130  cases  of  rheumatic  gout  admitted 
during  the  same  period ;  and  it  has  sufTered  more  or  less  sevctrely  in  five  out  of  75 
cases,  which  liave  fallen  under  my  own  care  at  the  hospital."     (Fuller.) 


23G  GONORRHCEAL    RHEUMATISM. 

tliat  form  of  "  2;onorrli<cal  ophthalmia"  which  has  been  described  by  au- 
thors as  "  metastatic  or  sympathetic  ;"  but  the  difference  in  the  mode  of 
origin,  symi)toms,  prognosis,  and  treatment,  between  this  form  of  o|)htlial- 
mia  and  pm-ulent  conjunctivitis  arising  from  contagion,  is  so  great,  that  it 
would  be  desirable  to  distinguish  the  two  by  different  names,  and  to  drop 
altogether  the  term  gonorrhceal  ophthalmia,  as  applied  to  that  ocular  affec- 
tion which  accomj)anies  gonorrhocal  rheumatism. 

In  the  first  two  editions  of  tliis  work  I  published  a  resnme  of  twenty- 
seven  cases  which  I  had  been  able  to  collect  from  various  sources  of  so- 
ciilled  "  metastatic  gonorrhoea!  ophthalmia,"  and  from  which  I  drew  the 
following  conclusions : — 

In  all  the  cases  the  eye-disease  was  preceded,  attended,  or  followed  by 
rheumatism.  In  a  majority  of  the  attacks  the  ophthalmia  preceded  the 
rheumatism. 

In  about  two-lhirds  of  the  cases  of  which  we  have  sufficient  details  to 
enalde  us  to  determine  the  seat  of  the  ophthalmia,  the  sclerotica  and  iris 
were  chiefly  affected  ;  in  the  remaining  third,  the  conjunctiva.  In  the 
latter  class,  it  is  sometimes  noted  tliat  there  was  purulent  discharge  and 
chemosis ;  but  the  inflammation  does  not  appear  to  have  assumed  the 
severity  of  gonorrhoeal  ophthalmia  from  contagion,  since  only  one  case 
terminated  in  ulceration  of  the  cornea,  and  most  of  the  cases  yielded 
reiidily  to  treatment. 

We  may  conclude,  therefore,  that  gonorrhceal  rheumatism,  like  rheu- 
matic gout,  may  attack  any  of  the  ocular  tunics,  though  it  most  frequently 
involves  the  sclerotica,  from  which  it  may  extend  to  the  conjunctiva,  iris, 
or  other  tissues.^  It  must  be  borne  in  mind  tliat  the  vascular  connection 
of  all  the  tissues  of  the  eye  is  very  intimate,  and  that  the  inflammatory 
process  is  never  wholly  confined  to  one  portion  of  the  globe.  It  is  highly 
probable,  I  think,  that  many  cases  of  gonorrhoeal  rheumatic  ophthalmia, 
whicli  have  been  described  as  conjunctivitis,  have  in  reality  been  instances 
of  coujunctivo-sclerotitis,  in  which  the  injection  of  the  conjunctival  ves- 
sels has  masked  that  of  the  sclerotica.  The  orbital  and  circumorbital  pains, 
which  are  often  mentioned,  would  indicate  this.  At  the  same  time,  it  must 
be  confessed,  that  in  some  instances  the  chief  seat  of  the  disease  has  been 
the  conjunctiva,  and  that  tlie  presence  of  a  muco-purulent  discharge  and  a 
certain  degree  of  chemosis,  have  rendered  these  cases  readily  mistakable 
for  gonorrhoeal  ophthalmia  from  contagion.  The  milder  character  of  the 
disease,  the  history  and  habits  of  the  patient,  and  the  existence  of  rheu- 
matism, are,  in  such  instances,  the  chief  elements  on  which  to  found  a 
diagnosis.  When  a  [latient  has  had  an  affection  of  the  eyes  and  joints  in 
previous  attacks  of  gonorriioea,  or  when  gonorrlujcal  rheumatism  coexists 
with  an  ophthalmia  which  does  not  present  the  severe  symptoms  of  puru- 
lent conjunctivitis,  there  is  a  strong  {)robability  that  it  is  of  the  rheumatic 
form,  even   though  the  conjunctiva  appears  to  be  chiefly  affected.     Not 

'  Those  cases  do  not  confirm  Rollet's  statement,  tliat  gonorrhoeal  rheumatic 
ophthalmia  is  always  a  kerato-iritis. 


DIAGNOSIS.  237 

uiifrequently,  also,  rheumatic  oplitlialmia,  after  entirely  disappearing  from 
one  eye,  involves  the  opposite  eye  or  returns  a  second  time  to  the  one  first 
affected,  a  course  never  pursued  by  gonorrhoeal  ophtiialmia  from  contagion. 

In  "by  far  the  larger  proportion  of  cases,  however,  the  symptoms  of 
gonorrlioeal  rheumatic  ophthalmia  are  those  of  sclerotitis,  iritis,  or  kerato- 
iritis,  either  separate  or  combined.  I  shall  not  attempt  to  describe  the 
characteristic  features  of  these  different  forms,  since  they  are  identical 
with  those  of  the  same  affections  arising  from  other  causes. 

I  will  merely  remark  that  when  the  iris  is  involved,  it  generally  appears 
to  be  so  secondarily,  and  that  the  inflammation  affects  it  to  a  less  extent 
and  more  superficially  than  in  other  forms  of  iritis ;  hence  that  there  is 
less  danger  of  adhesions  to  the  capsule  of  the  lens  and  of  atresia  iridis,  and 
that  tubercular  excrescences  are  probably  never  seen  upon  its  surface. 

Diagnosis The  admission  of  gonorrhoeal  rheumatism  as  a  distinct 

disease,  is  by  no  means  dependent  upon  the  question  whether  it  presents 
any  symptoms  different  from  those  of  ordinary  rheumatism.  Inflammation 
of  the  epididymis,  identical  with  swelling  of  the  testicle  attendant  upon 
gonorrhtea,  may  be  excited  by  other  causes;  and  even  if  no  diagnostic 
signs  of  the  rheumatism  caused  by  urethritis  be  admitted,  we  should  still 
be  warranted  in  using  the  term  "  gonorrhoeal  rheumatism"  as  indicating 
the  connection  between  the  two  diseases. 

It  is  evident,  however,  that  the  disease  now  under  consideration  differs 
in  some  respects  both  from  acute  rheumatism  and  rheumatic  gout,  though 
much  more  closely  allied  to  the  latter  than  to  the  former. 

It  differs  from  acute  rheumatism  in  the  absence  or  slightly  marked 
character  of  its  premonitory  symptoms  ;  in  the  less  degree  of  constitutional 
disturbance  wiiich  attends  it ;  in  being  limited  to  a  few  joints  ;  in  its  pre- 
dilection for  the  synovial  membranes ;  in  rarely  attacking  the  heart,  but 
frequently  the  eye  ;  in  its  persistency  ;  and  in  seldom  affecting  women. 
It  differs  from  rheumatic  gout  in  the  fact  that  hereditary  influences,  so 
far  {IS  at  present  jjroved,  have  no  part  in  its  production  ;  also  in  the  fre- 
quency with  which  it  attacks  the  knee-joint  ;  in  its  preference  for  the 
male  sex  ;  and  in  its  rarely  leaving  any  permanent  traces  of  its  invasion. 

In  a  given  case  of  this  kind,  therefore,  it  may  at  times  be  extremely 
difficult  to  determine  whether  our  patient  has  an  affection  of  the  joints 
dependent  upon  his  urethritis,  or  wiietlier  his  rheumatism  is  simply  a 
coincidence  ;  if,  however,  there  be  but  little  constitutional  disturbance  ;  if 
only  a  few  joints,  and  particularly  the  knee,  be  affected  ;  if  the  disease  be 
chiefly  confined  to  the  synovial  menibrane — as  sliown  by  the  articular  effu- 
sion, and  the  slight  degree  of  heat  and  re<lness  externally — and  if  it  exhibit 
but  slight  tendency  to  migrate  from  one  joint  to  another,  then  there  can 
be  little  question  that  the  gonorrhoea  and  rheumatism  bear  to  each  other 
the  relation  of  cause  and  effect.  The  probability  will  be  still  further 
strengthened,  if  the  patient  has  never  been  subject  to  rheumatism  ;  or,  d 
fortiori,  if  he  has  had  it  only  in  conjunction  with  previous  attacks  of 
gonorrhoea. 


238  GONORRHCEAL    RHEUMATISM. 

Nature The  power  of  exciting  rheumatism,  exercised  by  gonorrhoea 

in  certain  cases,  has  often  been  advanced  as  an  argument  to  prove  that 
the  latter  disease  is  a  modified  form  of  syphilis ;  and  it  has  been  asserted 
that  the  rheumatism  is  due  to  the  absorption  of  a  specific  poison  from  the 
urethra.  This  idea  has  probably  derived  additional  weight  from  the  sup- 
position that  no  other  satisfactory  explanation  could  be  given  of  the  con- 
nection between  these  two  diseases,  and  before  such  was  tbund,  the  theory 
of  a  syphilitic  or  gonorrhoeal  virus  was  thought  to  be  the  only  alternative. 
The  question  has  been  asked :  If  the  rheumatism  is  not  produced  by  the 
absorption  of  a  specific  poison,  how  is  it  produced  ?  But  such  a  process 
of  reasoning  is  founded  on  a  gross  over-estimate  of  our  knowledge  of  cause 
and  effect  in  disease.  Tiie  connection  between  gonorrhoea  and  rheuma- 
tism is  only  one  of  many  instances,  in  which  the  link  which  binds  two 
diseases  together  escapes  us,  although  the  union  is  plain  and  unquestion- 
able. Who,  for  instance,  can  account  for  the  intermittent  fever  which  is 
sometimes  occasioned  by  a  stricture  of  the  urethra;  or  explain  the  con- 
nection between  chorea  and  rheumatism — a  connection  so  intimate  tliat  a 
large  proportion  of  children  who  have  the  one  will  have  the  other ;  or  the 
reason  that  disease  of  the  supra-renal  capsules  causes  bronzing  of  the  skin  ? 
And  so  tliroughout  the  etiology  of  all  diseases,  if  for  a  moment  we  endeavor 
to  divest  our  minds  of  the  familiarity  which  daily  observation  has  given  to 
the  connection  between  them  and  the  causes  which  produce  them,  in  how 
few  instances  do  we  really  understand  the  mechanism  of  the  process! 

Facts  which  occur  but  rarely,  excite  wonder  ;  if  frequent  or  coinciding 
Avith  other  known  phenomena,  the  mind  receives  them  without  distrust. 
Is  it  then  an  isolated  fact  tliat  a  local  affection,  entirely  destitute  of  spe- 
cific properties,  is  capable  of  exciting  rheumatism  ?  By  no  means.  Dr. 
Fuller,  who  believes  that  the  proximate  cause  of  rheumatism  is  a  poison 
generated  in  tiie  system  (not  absorbed  from  without)  as  the  result  of  faulty 
metaniorphic  action,  thus  speaks  of  the  infiuence  of  local  disease :  "  One 
part  of  tiie  animal  economy  hinges  so  closely  on  the  other,  that  local  mis- 
chief occasions  general  disturbance,  and  under  certain  circumstances 
appears  to  induce  a  state  of  system  favorable  to  tlie  generation  of  the  rheu- 
matic poison  ;  a  state  of  system  arising,  be  it  observed,  not  as  a  direct  and 
immediate  consequence  of  suspended  secretion,  but  as  a  sequel  of  perverted 
function  gradually  taken  on  by  the  sA^stem  generally,  in  consequence  of 
imperfect  or  morbid  local  action.  P^xcessive  venery  and  long-continued 
debauciiery  are  frequently  productive  of  riieumatism,  and  so  is  immoder- 
ately protracted  lactation.  The  plienomena  of  gonorrhoja  afford  an 
admirable  example  of  how  local  diseases  gradually  give  rise  to  general 
derangement  of  the  system,  and  so  to  the  production  of  the  peccant  matter 
of  riieumatism."^  This  connection  between  local  diseases  in  general  and 
inflammation  of  the  joints  is  also  fully  recognized  by  other  observers  ;  it 
need  not  tlierefore  surprise  us,  nor  is   there  any  necessity  to  suppose  the 

'  Fuller  on  Rheumatism,  p.  35. 


TREATMENT.  239 

absorption  of  a  specific  poison,  when  we  find  that  rheumatism  can  be  ex- 
cited by  inflammation  of  the  urethra. 

Moreover,  evidence  is  not  wanting  to  show  that  the  phenomena  of 
gonorrliceal  rheumatism  cannot  be  explained  on  the  ground  that  the  syphi- 
litic or  any  other  specific  poison  has  been  taken  into  the  system  from 
without.  In  order  not  to  extend  this  subject  to  too  great  length,  I  will 
merely  enumerate  the  chief  points  of  this  evidence : — 

1.  If  gonorrhoeal  rheumatism  were  due  to  the  absorption  of  a  virus,  it 
ought  to  be  a  very  frequent  disease,  considering  the  multitude  of  patients 
atfected  with  gonorrhoea  ;  it  is,  however,  quite  infrequent. 

2.  On  the  same  supposition,  it  ought  to  run  a  regular  and  definite 
course,  like  specific  diseases  in  general. 

3.  One  attack,  also,  should  afford  immunity  from,  or  at  least  partial 
protection  against,  subsequent  attacks  in  the  same  person. 

4.  No  evidence  of  the  absorption  of  a  virus  is  found  in  an  examination 
of  the  lymphatic  vessels  or  ganglia  in  gonorrhoea,  as  in  syphilis.  Even  in 
cases  of  gonorrhoeal  rheumatism,  the  absorbents  in  the  neighborhood  of 
the  genital  organs  retain  their  normal  condition. 

5.  Urethral  rheumatism  has  repeatedly  been  known  to  occur  in  connec- 
tion with  urethritis  which  had  been  excited  by  the  use  of  bougies,  or  by 
intercourse  with  women  during  the  menstrual  period.  If  it  can  thus  be 
caused  by  a  simple  urethritis,  wiiy  is  it  ever  necessary  to  attribute  it  to  a 
"  virulent  gonorrhoea?" 

6.  None  of  the  known  symptoms  of  syphilis  bear  any  more  than  the 
slightest  resemblance  to  gonorrhoea. 

Treatment It  is  evident  that  we  cannot  deduce  the  treatment  of 

gonorrlueal  rheumatism  from  that  of  acute  rheumatism,  as  has  sometimes 
been  done  by  writers  on  this  subject ;  nor,  again,  entirely  from  that  of 
rheumatic  gout,  although  here  it  is  not  improbable  that  a  somewhat  similar 
line  of  treatment  may  be  found  applicable.  But  if  we  recognize  a  special 
cause  and  certain  peculiarities  in  the  symptoms  of  gonorrhoeal  rheumatism, 
the  treatment  of  this  disease  demands  investigation  independent  of  any 
[)reconceived  notions  derived  from  our  experience  with  kindred  affections. 

The  amount  of  constitutional  disturbance  attending  the  commencement 
of  an  attack  of  gonorrhoeal  rheumatism  is  rarely  sufficient  to  require  active 
antiphlogistic  measures.  The  administration  of  an  emetic,  or  a  free  purge, 
as  Irom  five  to  ten  grains  of  calomel,  followed  by  castor  oil  or  P^psom  salts, 
is  commonly  sufficient  to  allay  the  febrile  excitement,  and  has  the  addi- 
tional advantage  of  correcting  the  condition  of  the  digestive  organs,  which 
are  utiually  at  %ult.  Rest  is  of  the  first  importance,  and  the  diet  should 
be  proportioned  to  the  severity  of  the  febrile  action.  The  chief  means  of 
combating  the  local  inflammation  is  to  be  found  in  the  abstraction  of  blood 
from  the  neighborhood  of  the  joints.  Cups  or  leeches  may  be  ap{)lied,  and 
repeated  as  often  as  the  case  requires.  They  aftbrd  marked  relief  to  the 
pain,  often  arrest  the  progress  of  the  disease,  and  hasten  its  resolution. 

After  the  more  acute  symptoms  have  been  subdued,  or  even  at  the  out- 


240  GONORRHEAL    RHEUMATISM. 

set,  when  the  disease  is  from  the  first  of  a  subacute  character,  the  greatest 
benefit  will  be  derived  from  blisters.  These  are  especially  applicable, 
when  a  large  joint,  like  the  knee,  is  attacked,  and  when  an  effusion  within 
the  capsule  is  a  prominent  symptom.  The  vesicated  surface  may  be 
dressed  with  simple  cerate  with  the  addition  of  five  grains  of  morphine  to 
each  ounce,  and  so  soon  as  the  suriace  heals  a  fresh  blister  may  be  ap- 
plied. If  strangury  ensue,  the  daily  application  of  strong  tincture  of  iodine 
may  be  substituted  for  the  unguentum  lytta;.  Velpeau  recommends  that 
the  joint  be  kept  constantly  smeared  with  mercurial  ointment,  to  which 
some  [)reparation  of  opium  has  been  added. 

Dieulafoy'  has  employed  aspiration  in  cases  of  effusion  into  the  knee- 
joint  from  gonorrh(jeal  rheumatism,  but  states  that  such  cases  are  peculiar 
and  more  obstinate  than  those  in  which  the  effusion  is  dependent  upon 
other  causes.  The  puncture  of  the  knee  gives  relief,  but  the  liquid  soon 
forms  again. 

Ricord  and  some  other  writers  advise  the  internal  administration  of 
colchicum,  alkalies,  and  the  salts  of  potash,  as  in  rheumatism  dependent 
upon  other  causes,  but  the  reports  of  cases  in  which  these  remedies  have 
been  employed  are  far  from  proving  their  ethcacy. 

Prof.  Hardy^  has  employed  the  salicylate  of  soda,  now  so  much  in  vogue 
for  articular  diseases,  and  reports  that  under  its  influence  the  spontaneous 
pains  have  diminished,  but  those  felt  on  walking  were  just  as  severe.  In 
short,  the  salicylate  does  not  seem  to  exert  the  same  beneficial  effect  as  in 
ordinary  articular  rheumatism. 

The  occasional  use  of  an  emetic  or  purge  has  in  the  hands  of  several 
surgeons  been  found  to  be  of  decided  advantage.  Rollet  speaks  highly 
of  vapor  baths.  Copaiba  and  cubebs  have  no  effect  upon  the  rheumatism, 
and  can  only  be  required  for  the  uretiiritis,  which,  in  most  cases,  however, 
is  more  satisfactorily  treated  by  local  measures. 

Meanwhile  the  treatment  of  the  urethral  discharge  on  which  the  rheu- 
matism depends  should  not  be  neglected.  Unless  this  be  entirely  arrested, 
there  is  always  danger  of  a  relapse.  In  many  of  the  cases  reported,  the 
rheumatism  has  repeatedly  returned  at  intervals  of  several  months,  so  long 
as  the  exciting  cause  continued.  The  measures  already  recommended 
for  the  treatment  of  gonorrluea  and  gleet  should,  therefore,  be  actively 
employed,  at  the  same  time  that  attention  is  paid  to  the  affection  of  the 
joints. 

When  gonorrhccal  rheumatism  occurs  in  persons  of  broken-down  consti- 
tution, or  when  the  general  health  becomes  impaired  by  the  continuance 
of  the  urethral  and  articular  disease,  it  is  necessary  to  resort  to  hygienic 
measures,  and  frequently  to  the  administration  of  tonics,  as  preparations 
of  iron,  iodine,  cod-liver  oil,  bark,  etc.  These  remedies,  togetiier  with 
fresh  air  and  good  diet,  should  by  no  means  be  neglected  as  soon  as  the 
patient  is  i'ound  to  be  debilitated.     Barwell  believes  that  gonorrhoeal  rheu- 

I  Gaz.  hebd.  de  med.,  Paris,  Feb.  22,  1878. 
«  Gaz.  d.  hop.,  Paris,  No.  149,  1877. 


TREATxMENT.  241 

matism  depends  upon  slight  purulent  infection,  and  recommends  large  doses 
of  quinine. 

A  very  efficacious  method  of  treating  the  swelling,  which  often  remains 
after  the  acute  symptoms  have  subsided,  is  by  means  of  strips  of  adhesive 
plaster  so  applied  as  to  exercise  compression  and  at  the  same  time  render 
the  joint  immovable.  Supposing  the  knee  to  be  affected,  the  limb  should 
be  bandaged  from  the  toes  up  to  the  point  where  the  plaster  is  to  com- 
mence, or  just  below  the  swelling.  The  strips  should  be  of  about  two 
fingers'  breadth,  and  each  one,  first  passed  behind  the  limb,  be  brought 
round  in  front,  and  its  ends  made  to  cross  like  the  letter  X.  One  strip 
after  another  is  applied,  each  overlapping  the  preceding  for  about  one- 
third  its  width,  until  the  whole  joint  is  covered,  when  four  or  five  addi- 
tional layers  are  superposed  in  the  same  manner  in  order  to  insure  a 
sufficient  degree  of  stiffness,  and  the  whole  enveloped  in  a  bandage.  I  can 
speak  very  decidedly  of  the  good  effects  of  this  application  in  this  and 
other  chronic  affections  of  the  joints. 

Mr.  Milton,^  whose  accurate  and  systematic  observations  are  always 
worthy  of  quotation,  formerly  employed  in  the  acute  stage  the  hydro- 
chlorate  of  ammonia  in  half  drachm  doses  every  two  or  three  hours,  and, 
if  this  failed,  the  nitrate  of  potassa  in  scruple  or  half-drachm  doses  every 
three  or  four  hours.  After  the  severity  of  the  disorder  was  checked,  he 
resorted  to  the  iodide  of  potassium  and  the  wine  of  colchicum,  the  latter 
to  be  given  in  no  less  doses  than  a  couple  of  drachms  daily,  and  the  affected 
joint  was  to  be  blistered. 

More  recently,  however,  Mr.  Milton,  ''  doubting  whether  I  (he)  was  not 
searching  in  a  wrong  direction,"  has  tried  in  one  or  two  cases  in  debili- 
tated subjects  a  mode  of  treatment  which,  he  says,  has  proved  highly  suc- 
cessful and  which  is  so  agreeable  as  to  lead  any  patient  suffering  with  this 
disease  to  place  himself  under  his  care.  This  treatment  consists  in  the 
administration  of  a  bottle  of  Burgundy  daily,  a  large  glass  of  good  milk 
and  the  best  rum  at  bedtime,  a  restorative  diet  including  plenty  of  fat  ham 
and  bacon,  quinine  in  five-grain  doses  three  times  a  day,  an  aperient  pill 
containing  colchicum  to  keep  the  bowels  open,  the  bimeconate  of  morphia 
if  a  sedative  is  required,  and  a  sulphur  fume  bath  occasionally,  to  be  fol- 
lowed by  a  va{)or  bath  ! 

When  the  eye  becomes  inflamed,  local  depletion  by  means  of  leeclies  or 
cups  to  the  temples  may  be  called  for.  If  the  conjunctiva  be  involved, 
the  strictest  cleanliness  should  be  maintained  by  frequent  bathing  w^ith 
tepid  water.  Astringent  collyria  are  less  frequently  called  for  than  in  con- 
junctivitis independent  of  any  rheumatic  taint ;  if  used,  their  effect  should 
be  carefully  watched,  and  if  they  fail  to  afford  relief,  tiiey  should  be 
omitted.  When  the  iris  is  implicated,  the  pupil  must  be  dilated  by  atro- 
pine, and  mercurials  administered  as  in  other  forms  of  iritis. 

'  Pathology  and  Treatment  of  Gon.,  4th  ed.,  1870,  p.  273. 
IG 


242  VEGETATIONS. 


CHAPTER   XXII. 

VEGETATIONS. 

Vegetations  are  papillary  growths  springing  from  the  skin  or  mucous 
membrane,  chiefly  in  the  neighborhood  of  the  genital  organs,  and  identical 
in  their  nature  with  tlie  warts  which  are  so  common  upon  the  hands. 
Tliey  are  not,  strictly  speaking,  venereal,  since  they  are  not  necessarily 
connected  with  either  of  the  diseases  originating  in  sexual  intercourse. 
It  is  true  that  they  are  most  frequently  observed  in  men  and  women  who 
have  been  affected  with  gonorrhoea,  balanitis,  chancroids,  or  syphilis  ; 
but  this  is  simply  because  the  skin  or  mucous  membrane  has  for  a  time 
been  moistened  wdth. an  acrid  secretion  which  has  favored  the  abnormal 
development  of  its  papillfe.  They  are  found  in  young  children,  with  re- 
gard to  whose  purity  there  can  be  no  suspicion  ;  and  also  in  adults  who 
have  never  suffered  from  any  venereal  disease  whatsoever.  Again,  they 
are  not  unfrequently  met  with  during  pregnancy  ;  the  increased  secretion 
from  the  vagina  and  the  determination  of  the  blood  to  the  pelvis  at  this 
time  being  highly  favorable  to  their  development. 

The  importance  of  these  growths  has  been  very  much  exaggerated. 
Thus,  they  have  been  regarded  as  syphilitic  and  as  an  indication  of  the 
necessity  for  specific  remedies ;  and  this,  too,  in  spite  of  the  generally 
recognized  fact  that  mercury  has  no  effect  whatever  in  their  removal. 
Their  only  connection  with  syphilis  is  when  they  spring  from  the  surface 
of  a  chancre,  mucous  patch,  or  other  general  lesion,  upon  which  they  are 
a  merely  accidental  formation.  The  sore  Avhich  serves  as  their  base  may 
require  a  mercurial  course,  but  the  superadded  vegetation  in  itself  presents 
no  such  indication. 

Again,  it  is  often  said  that  they  are  contagious  ;  and  some  semblance  of 
truth  for  this  supposition  has  been  found  in  the  fact  that  when  situated 
upon  one  of  two  opposed  surfaces,  as  the  labia  or  upper  and  inner  parts  of 
the  thighs,  similar  growths  not  unfrequently  spring  up  upon  the  opposite; 
and  somewhat  doubtful  cases  have  been  reported  in  which,  as  alleged, 
vegetations  have  appeared  upon  men  after  connection  with  women  who 
were  similarly  affected.^     But  such  instances  are  readily  explained  on  the 

'  Thus,  long  since  the  above  was  written,  we  read  in  Zcissl  (op.  cit.,  3d  ed., 
1875,  T.  I.,  p.  150),  that  he  has  frequently  observed  the  development  of  vegeta- 
tions in  i>ersons  who  had  for  some  time  had  intercourse  with  the  opposite  sex 
affected  in  the  same  manner.  He  also  quotes  Dr.  Lindwurm,  of  Munich,  as  having 
successfully  inoculated  vegetations.  Yet  Zeissl  does  not  believe  that  there  is  any- 
thing specific  in  these  excrescences. 


VEGETATIONS.  243 

ground  that  the  acrid  secretion  from  vegetations,  when  applied  to  neio-h- 
boring  parts,  and  possibly,  when  transferred  to  another  individual,  acts  in 
the  manner  already  explained,  and  gives  rise  to  others.  The  very  fact 
that  their  supposed  contagion  takes  place  upon  the  person  affected,  is  suffi- 
cient to  prove  that  they  are  not  dependent  upon  the  virus  of  true  syphilis, 
the  lesions  of  which  are  not  auto-inoculable  ;  and  there  is  no  reason  what- 
ever for  ascribing  them  to  tlie  poison  of  the  chancroid.  Moreover,  they 
present  the  same  aspect,  follow  the  same  course,  and  are  amenable  to  the 
same  treatment,  when  occurring  in  young  cliildren  and  pregnant  women 
who  are  otherwise  healthy,  as  in  persons  affected  with  venereal  diseases. 

Several  varieties  of  vegetations  have  been  admitted,  especially  by  the 
French,  founded  upon  their  resemblance  to  various  objects  in  nature. 
Thus,  Alibert,  who  believed  that  vegetations  were  syphilitic,  admitted 
them  as  one  of  tliree  principal  forms  of  the  syphilodermata ;  and  divided 
tliem  into  six  varieties  :  "  La  syphilis  vegetante  framboisee  ;"  "  en  choux 
fieurs  ;"  "  en  cretes  ;"  "  en  poireaux  ;"  and  "  en  vermes  ;"  to  wliich  he 
added  the  truly  syphilitic  lesion,  mucous  patches,  under  the  head  of 
"  condylomes." 

No  useful  purpose,  however,  is  attained  by  this  classification,  which 
serves  only  to  confuse  the  mind  ;  since  the  form  of  vegetations  is  solely 
dependent  upon  accidental  circumstances,  as  their  position  and  the  pres- 
sure of  neighboring  parts.  It  is  sufficient  to  know  that  they  are  sometimes 
flat  and  but  little  elevated  above  the  surface  ;  while  at  others  they  are 
attached  by  means  of  a  pedicle  of  variable  diameter :  and  that  they  are 
chiefly  developed  in  whatever  direction  they  meet  with  the  least  resistance. 
When  exposed  to  the  air  they  are  often  dry  and  hard ;  when  protected  by 
an  opposed  surface,  they  are  soft  and  smeared  with  a  highly  offensive 
secretion. 

Their  microscopical  appearances  are  thus  described  by  Lebert :  "A 
feeble  power  shows  their  internal  vascular  structure  and  numerous  seba- 
ceous follicles  about  their  base.  With  a  high  power,  the  pa[)illa3  appear 
to  be  composed  of  an  outer  rind  consisting  of  concentric  layers,  and  of 
an  internal  substance ;  the  two  differ  from  each  other  only  in  density  ; 
for,  besides  their  vascular  element,  they  consist  only  of  epidermic  cells. 
In  the  outer  layers,  these  cells  are  more  densely  packed  and  present  a 
longer  and  narrower  outline,  which,  at  first  sight,  gives  tliem  a  fibrous 
appearance.  The  internal  portion  is  also  composed  of  epidermic  cells  in 
close  juxtaposition,  but  round  and  finely  dotted  on  their  surface.  Vegeta- 
tions are  nothing  else  tlian  a  development  of  the  papillie  of  tlie  cutis,  and, 
in  tlieir  anatomical  composition,  do  not  differ  mucli  from  certain  papilli- 
form  warts." 

Vegetations  are  most  frequently  met  witli  upon  tlie  internal  surface  of 
the  prei)uce  directly  back  of  the  furrow  at  the  base  of  tlie  glans  ;  they  are 
also  found  upon  the  margin  of  the  meatus,  or  within  this  orifice  upon  the 
walls  of  the  fossa  navicularis  ;  upon  the  vulva  in  women,  and  especially  in 
the  neighborhood  of  the  carunculaj  myrtiformes;  and,  in  both  sexes,  around 
the  anus,  upon  the  tongue,  velum  palati,  and  even  within  the  larynx. 


244  VEGETATIONS. 

Treatment The  treatment  of  vegetations  consists  simply  in   their 

removal  by  the  knife,  scissors,  Wolkmann's  spoon,  caustic,  or  ligature,  and 
the  destruction  of  the  base  from  wliich  they  spring.  With  the  vegetations 
upon  the  internal  surface  of  the  prepuce,  I  have  found  it  most  convenient 
to  touch  them  with  glacial  acetic  acid  or  with  fuming  nitric  acid,  and  re- 
peat the  application  upon  the  fall  of  the  eschar  as  often  as  may  be  neces- 
sary; or,  when  prominent  and  pedunculated,  they  may  be  snipped  off  with 
scissors,  and  their  base  thoroughly  cauterized,  although,  when  cutting 
instruments  are  used,  the  hemorrhage  is  sometimes  a  little  troublesome  ; 
hence,  when  practicable,  a  ligature  is  to  be  preferred.  A  small  AVolk- 
mann's  spoon  with  a  cutting  edge  is  also  useful  in  the  removal  of  vegeta- 
tions whether  prominent  or  flat,  and  has  the  advantage  of  not  being  formi- 
dable to  the  patient.  It,  however,  removes  only  the  outgrowth  and  does 
not  attack  the  root,  which  will  still  require  the  application  of  caustic.  As 
soon  as  the  tenderness  produced  by  the  application  of  caustic  has  subsided, 
it  is  desirable  to  keep  the  glans  uncovered  in  order  to  harden  the  internal 
layer  of  the  prepuce  by  exposure  to  the  air  and  friction ;  and,  unless  the 
preputial  orifice  is  very  narrow,  this  may  generally  be  accomplished  by 
wearing  for  a  few  days  a  narrow  bandage  round  the  penis  posterior  to  the 
glans.  Special  attention  should  also  be  paid  to  removing  any  collection  of 
the  smegma  prceputii,  and  keeping  the  parts  perfectly  clean. 

The  above  acids  act  so  ftxvorably,  that  I  have  seldom  resorted  to  other 
caustics,  with  the  exception  of  chromic  acid,  which  has  come  into  favor 
within  a  few  years. ^  A  solution  of  this  acid  (one  hundred  grains  to  the 
ounce  of  water)  is  a  powerful  escharotic,  and  is  especially  useful  in  those 
obstinate  cases  in  which  the  vegetation  repeatedly  returns  after  removal ; 
but  it  should  be  applied  with  caution,  simply  moistening  the  surface  of  the 
morbid  growth  and  sparing  the  healthy  tissues  in  the  neighborhood,  or 
otherwise  it  is  apt  to  induce  severe  pain  and  inflammation. 

Again,  a  solution  of  corrosive  sublimate  in  collodion  (3J  ad  sj)  may  be 
applied  over  the  whole  surface  of  the  growth. 

In  vegetations  of  considerable  size,  it  has  been  suggested  to  inject  into 
the  substance  of  the  tumor  by  means  of  a  hypodermic  syringe  from  half  a 
drop  to  several  drops  of  strong  acetic  acid. 

The  perchloride  or  peri^ulpliate  of  iron  is  often  of  service.  It  is  sufiicient 
in  many  cases  to  give  the  patient  a  prescription  for  the  liquor  fei-ri  per- 
sulphatis  and  direct  him  to  apply  it  once  or  twice  a  day  to  the  growtli, 
wliich  soon  shrivels  up  and  falls  ot^',  when  a  few  further  a[)plications  to  the 
base  will  prevent  its  return. 

The  tincture  of  tliuja  occidentalis  as  a  local  application  has  been  recom- 
mended especially  by  Dr.  J.  11.  Leaming,  of  New  York.  The  homoeo- 
paths administer  the  same  internally  in  doses  of  one  drop  while  using  it 
locally. 

'  See  Dublin  Quarterly  Journal  of  Mod.  Science,  vol.  xiii,  p.  250;  Eanking's 
Abstract,  vol.  xxv,  p.  149  ;  New  Orleans  Med.  News,  Nov.  1857. 


TREATMENT.  245 

For  the  removal  of  flat,  horny  vegetations  Zeissl  advises  an  ointment  of 
arsenious  acid  or  of  the  iodide  of  arsenic,  as  in  the  following  formulae : — 

K..     Acidi  Arseniosi  gr.  ij 112 

Unguenti  Hydrarg.  gj 4] 

M. 

R.     Arsenici  loiiidi  gr.  ij 112 

Unguenti  Hydrarg.  5j 4| 

M. 

The  same  author  confirms  the  statement  made  by  Dr.  Peters,  of  Prague, 
that  vegetations  which  have  resisted  all  forms  of  cauterization  and  even 
excision  will  sometimes  disappear  under  the  simple  application  of  cold 
poultices. 

Vegetations  about  the  vulva  may  be  treated  in  the  same  way  as  those 
upon  the  prepuce.  When  situated  around  the  margin  of  the  anus,  they 
are  generally  of  considerable  size,  and  require  to  be  snipped  off  with  scis- 
sors before  the  application  of  acid  to  the  base. 

Vegetations  during  pregnancy  may  appear  at  quite  an  early  period; 
they  grow  very  rapidly,  and  often  attain  an  immense  size.  I  have  seen  a 
mass  as  large  as  a  man's  arm,  extending  from  the  mons  veneris  to  the 
sacrum,  and  surrounding  the  vulva  and  anus.  During  gestation  no  opera- 
tive procedure  is  admissible;  but  the  pain,  itching,  and  offensive  odor  may 
be  palliated  by  careful  attention  to  cleanliness  and  lotions  of  diluted  La- 
barraque's  solution,  followed  by  the  application  of  calomel  or  of  some 
astringent  powder,  as  equal  parts  of  savin  and  burnt  alum.  After  delivery, 
they  often  disappear  spontaneously,  or  may  be  removed  by  the  knife  or 
caustic  ;  but  when  the  mass  is  very  large,  only  a  portion  should  be  attacked 
at  a  time.' 

Vegetations  situated  upon  a  chancre  or  mucous  patch  cannot  always  be 
distinguished  from  those  upon  the  .sound  integument ;  but  the  history  of 
the  case,  and  especially  the  coexisting  symptoms,  Avill  determine  when 
mercury  is  required  to  combat  syphilitic  infection  of  the  general  system. 

'  A  resume  of  the  articles  wliich  have  appeared  upon  vegetations  in  pregnant 
women  may  be  found  in  tlie  Gaz.  liebd.  do  med.,  Paris,  Feb.  8,  18G1. 


246  HERPES    PROGENITALIS. 


CHAPTER   XXIII. 
HERPES   PROGENITALIS. 

We  apply  the  term  herpes  progenitalis  to  an  inflammatory  vesicular 
affection,  which  occurs  upon  various  portions  of  the  genitals  of"  both  sexes, 
and  which  has  incorrectly  been  called  herpes  preputialis.  In  the  male  it 
occurs  most  commonly  on  the  inner  layer  of  the  prepuce,  and  less  frequently 
on  the  glans  and  on  the  integument  of  the  penis.  In  tlie  female,  the  inner 
surface  of  the  labia  majora,  both  surfaces  of  the  labia  minora  and  the  in- 
tegument around  the  vulva  are  its  favoi'ite  seats. 

The  number  of  vesicles  varies ;  frequently  there  is  but  one,  and  again 
they  are  quite  numerous  and  grou[)ed  together  often  in  a  circle  or  arc  of  a 
circle.  The  eruption  may  or  may  not  be  attended  by  any  unpleasant  sen- 
sation ;  usually,  however,  a  slight  burning  heat  and  itching  are  felt  at  the 
outset.  A  small,  red,  inflamed  spot  appears,  upon  which  the  vesicles 
rapidly  form.  In  some  cases  there  is  a  marked  inflammatory  areola,  which 
in  other  instances,  is  a  mere  rim  of  redness.  The  vesicles  vary  in  size  from 
a  pin's  head  to  half  a  pea.  When  unruptured,  we  find  a  rounded,  trans- 
lucent vesicle  containing  clear  serum.  Usually,  however,  owing  to  the 
thinness  of  the  epidermal  covering  and  the  moist  condition  of  the  membrane, 
rupture  takes  place  very  early.  Exceptionally,  and  especially  when  seated 
on  the  integument,  the  vesicles  remain  for  sevei'al  days,  and  their  contents, 
gradually  becoming  turbid  and  drying,  form  a  small  brownish  scab.  Rup- 
ture of  the  vesicle  leaves  a  shallow  exulceration,  corresponding  in  size  to 
the  vesicle.  Its  floor  is  at  first  of  a  deep  rosy  red,  with  a  finely  uneven 
surface.  Its  edges  are  sharply  cut  as  if  punched  out,  and  sometimes  a 
little  undermined,  but  never  to  the  same  extent  as  seen  in  the  chancroid. 
There  is  usually  no  tendency  of  the  ulceration  to  progress,  nor  do  the  sores 
fuse  together.  In  exceptional  instances,  however,  the  contrary  is  true, 
and  more  or  less  troublesome  ulcerations  occur.  This  is  not  unfrequently 
seen  in  the  early  stage  of  syphilis,  when  the  exulcerations  of  herpes  may  take 
on  all  the  cliaractei'istics  of  chancroids  and  run  a  similar  coarse.  They 
may  even  be  found  to  be  auto-inoculable,  and  also  give  rise  to  a  bul)o. 
AVhen  they  are  seated  upon  an  inflamed  prepuce  and  when  irritated  by 
contact  with  gonorrhoeal  pus,  more  or  less  destructive  tendency  is  also  apt 
to  show  itself. 

The  amount  of  inflammation  accompanying  these  vesicles  varies ;  in  some 
cases  there  is  but  little  heat,  redness,  and  swelling,  while  in  others  these 
are  well  marked.  We  have  sometimes  observed  the  vesicles  to  be  pre- 
ceded and  accompanied  by  severe  pain,  limited   sharply  to  their    area. 


HERPES    PROGENITALIS.  247 

Again,  we  have  found  the  exulcerations  covered  with  a  very  thin,  yellowish- 
white  film,  which  remains  for  a  considerable  time  in  an  indolent  condition, 
interfering  with  healing.  The  duration  of  herpes  varies  from  a  few  days 
to  two  weeks. 

Under  the  name  of  neuralgic  herpes,  Mauriac^  has  described  an  affection 
of  considerable  gravity,  in  which,  besides  the  herpetic  eruption,  there  is  an 
accompanying  neuralgia  of  various  branches  of  the  sacral  plexus  of  nerves. 
In  one  case  related  by  this  author,  a  patient,  who  for  eleven  days  previously 
had  felt  a  slight  sensation  of  heat  in  the  prepuce,  was  suddenly  attacked 
by  a  severe  prickling  and  intense  itching  in  the  part.  Mere  pressure  of 
the  clothes  became  insupportable,  and  the  patient  could  not  sleep  at  night, 
so  great  was  the  suffering.  Four  or  five  days  later  he  was  attacked  by 
darting  pains  down  the  leg,  and  in  the  perina^um,  buttocks,  and  scrotum. 
There  was  perversion  of  sensibility  in  the  same  parts,  anaesthesia  passing 
into  hypera?sthesia  and  the  reverse,  which  was  almost  unbearable.  Two 
years  later  the  patient  had  another  attack,  only  one  vesicle  being  present. 
He,  at  this  time  suffered  from  boring  pains,  neuralgia  of  the  urethra,  and 
disturbances  of  sensibility. 

In  a  second  case  observed  by  Mauriac,  there  were,  for  forty-eight  hours 
before  the  appearance  of  a  single  vesicle,  paroxysmal  pains  radiating  through 
the  penis  and  perina?um,  and  subsequently  darting  up  and  down  the  leg. 
A  short  time  after,  a  vesicle  appeared  at  the  orifice  of  the  meatus,  accom 
panied  by  liyperaeslhesia  of  the  urethra,  painful  micturition,  and  pain  in 
the  bladder.  We  have  also  seen  several  cases  of  vesicles  on  either  lip  of 
the  meatus,  attended  by  neuralgia  of  the  bladder  and  urethra.  The  canal 
itself  was  of  a  deep  red  color,  was  somewhat  swollen  and  bathed  with  a 
copious  mucous  secretion  in  which  no  pus-cells  could  be  detected.  The 
affection  lasted  about  a  week  and  was  for  the  first  few  days  very  painful. 

The  following  is  a  well-marked  case  of  neuralgic  herpes,  occurring  in 
our  own  practice  : — 

The  patient  was  a  man  35  years  old,  thin  and  i)ale,  but  of  average  general 
healtli.  His  father  and  his  sisters  had  for  years  been  subject  to  sciatica 
and  other  forms  of  neuralgia.  When  15  years  old  our  patient  was  attacked 
with  sciatica,  which  has  returned  as  often  as  four  times  a  year  for  the  last 
twenty  years.  The  attacks  are  sometimes  preceded  by  gastric  disturbance. 
The  pain  begins  just  above  tlie  knee  and  extends  upwards  to  the  gluteal 
region.  Genei'ally  about  the  fourth  day,  he  has  a  sensation  of  heat  and 
burning  on  the  side  of  the  penis  corresponding  to  the  sciatica,  and  very 
soon  a  group  of  vesicles  appears  which  is  quite  painful.  He  also  suffers  from 
burning  in  the  urethra,  and  mild  strangury  and  pain  on  the  same  side  of 
the  ^scrotum  as  tlie  sciatica.  Tiie  herpes  coexists  with  the  sciatica  in 
seven  out  of  ten  of  the  attacks. 

Herpes  progenitalis  is  very  prone  to  relapse  at  longer  or  shorter  inter- 
vals, sometimes  with  distinct  periodicity.     It  is  usually  unattended  by  any 

'  LeQoiis  sur  I'lierpe.s  nevralgif|ue  des  organes  genitaux,  Paris,  1878. 


248  HERPES    TROGENITALIS. 

cliange  in  the  inguinal  ganglia,  but  in  some  severe  cases  the  latter  are 
slightly  swollen  and  painful  for  a  few  days.  In  a  few  instances,  when  the 
vesicles  become  ulcerated,  suppurating  buboes  occur.  We  have  seen  these 
several  times,  especially  in  syphilitic  subjects,  and  we  think  that  most 
authors  are  too  positive  as  to  the  immunity  of  these  glands  in  herpes 
progenitalis. 

This  affection  must  be  regarded  as  neurotic  in  its  nature,  and  its  excit- 
ing cause  peripheral  irritation  of  the  nerves  of  the  penis.  Thus  it  is  often 
developed  for  the  first  time  after  the  cure  of  a  chancroid,  and  some  think 
especially  in  those  cases  which  have  been  treated  by  active  cauterization. 
A  long  prepuce  and  the  low  grade  of  balanitis,  which  so  often  accompanies 
that  condition,  are  quite  common  causes,  while  frequent  sexual  inter- 
course, excessive  alcoholic  indulgence  and  rich  food  are  known  to  produce 
relapses.  The  vaginal  secretion  of  some  women  has  been  known  to  cause 
outbreaks  of  this  eruption.  "VVe  can  recall  the  case  of  a  gentleman,  who, 
prior  to  his  marriage,  had  had  intercourse  with  many  women  with  im- 
punity, but  who  was  attacked  by  herpes  after  each  act  of  coitus  with  his 
wife.  We  know  little  of  the  influence  of  a  rheumatic  or  gouty  diathesis 
as  causes  of  this  eruption,  although  they  are  recognized  by  some  physicians 
as  such.  The  neuralgic  form  of  herpes  is  luidoubtedly  of  central  origin 
and  merely  an  accompaniment  of  the  neuralgia  occurring  in  persons  of  a 
neurotic  tendency. 

The  diagnosis  of  herpes  in  most  cases  is  readily  made,  yet  the  exulcer- 
ated  vesicles  sometimes  closely  resemble  either  a  chancroid  or  chancre. 
In  general,  the  burning  and  itching  sensation  attending  the  invasion  of 
herpes,  the  superficial  character  of  the  ulcer,  its  less  profuse  secretion  and 
less  undermined  edges  will  establish  the  diagnosis,  while,  in  many  cases, 
the  history  of  frequent  relapses  will  point  directly  to  it. 

The  syphilitic  chancre  may  resemble  exulcerated  herpes  very  closely, 
not  only  in  its  solitary  but  multiple  form.  Fournier  very  aptly  says  that 
herpes  will  rarely  be  mistaken  for  a  chancre,  but  that  the  latter  may  be 
mistaken  for  herpes,  and  we  are  convinced  that  this  is  frequently  the  case. 
The  chancrous  erosion  is  an  exulceration,  but  its  color  is  of  a  deeper  and 
duller  red,  sometimes  even  coppery;  its  surface  is  smooth  and  shining 
without  any  unevenness  or  granulations.  There  is  no  undermining  of  its 
edges,  and  the  surrounding  areola  is  very  slight  and  of  a  deep,  dull-red 
color ;  in  short,  there  is  a  characteristic  absence  of  inflammation.  Although 
in  chancre  there  may  be  but  slight  oedema  of  the  base  for  a  few  days  re- 
sembling herpes,  distinct  induration  is  soon  felt.  Any  subjacent  hardness 
of  herpes  disappears  day  by  day,  while  that  of  the  chancre  increases. 
Then  too  in  syphilis  we  soon  have  induration  of  the  inguinal  ganglia. 
The  heat  and  burning  felt  either  prior  to  or  during  the  evolution  of  her- 
petic vesicles  is  also  a  valuable  diagnostic  sigu. 

As  its  name  denotes,  the  "  multiple  herpetiform  chancre"  presents  fea- 
tures resembling  those  of  exulcerated  hi'rpes  in  groups.  The  distinguish- 
ing signs  of  the  two  will  be  given  in  the  chapter  on  chancre. 


TREATMENT. 


249 


Treatment The  first  indication  is  to  remove  any  periplieral  irrita- 
tion which  may  exist.  Hence,  in  cases  of  a  long  and  tight  prepuce  cir- 
cumcision is  necessary,  and  we  have  often  seen  a  permanent  cure  from 
this  operation.  Even  in  the  absence  of  a  long  and  tight  prepuce,  there 
may  be  such  an  abundant  irritating  secretion  in  the  balano-preputial  fold 
as  to  require  careful  attention  to  cleanliness,  and  the  interposition  of  lint 
either  dry,  which  we  prefer,  or  wet  with  a  mildly  astringent  wash.  When 
herpes  follows  sexual  intercourse,  immediate  ablution  and  immersion  of 
the  penis  in  an  astringent  liquid  will  be  of  service.  In  all  cases  of  a  gouty 
and  rheumatic  tendency,  and  in  cases  of  dyspepsia,  appropriate  remedies 
should  be  used.  For  the  local  treatment  of  the  exulcerations  we  would 
recommend  the  interposition  of  dry  lint  or  the  application  of  dry  calomel 
or  some  other  absorbent  powder.  As  washes  we  sometimes  use  the  follow- 
insr : — 


M 


M 


Ai'genti  Nitrat. 
Aciuc-e  5j     .     . 


130 


301 


Ziiici  Snlpliat.  gr.  vj  .  . 
Spt.  Lavandulae  Comp.  5ss 
Aqufe  §ij 


136 


2 
601 


Acifli  Carbolici  gtt.  xx 1|30 

Glyceriiije  ,:^iij 12 

Aquam  ad  ^ij 60| 


250  STRICTURE    OF    THE    URETHRA. 


CHAPTER   XXIV. 

STRICTURE    OF    THE    URETHRA. 

Haying  considered  the  complications  of  gonorrhcca,  it  remains  to  speak 
of  one  of  the  most  frequent  and  important  results  of  the  same  disease, 
urethral  stricture. 

Anatomical  Considerations. 

An  acquaintance  with  the  anatomy  of  the  urethra — including  the 
character  of  its  lining  membrane,  the  fibrous,  muscular,  elastic,  and  erec- 
tile tissues  which  surround  it,  its  dimensions  and  direction — is  essential 
to  a  proper  appreciation  of  the  pathology  of  stricture  and  the  skilful  exe- 
tion  of  operative  procedures  requisite  in  its  treatment. 

The  male  urethra  is  naturally  divided  into  three  portions,  viz.,  the  pros- 
tatic, membranous,  and  spongy. 

The  prostatic  urethra  is  the  portion  included  in  the  prostate  gland,  and 
generally,  but  not  always,  traverses  this  body  at  the  union  of  its  middle 
and  upper  thirds.  Its  length  in  the  adult  is  about  one  inch  and  a  quarter; 
its  posterior  boundary  is  a  prominence  of  the  mucous  membrane,  called 
the  ^iinila  vesica  ;  its  cavity  is  fusiform,  largest  in  the  centre,  and  some- 
what contracted  towards  either  extremity.  Upon  its  floor,  a  short  dis- 
tance in  front  of  the  uvula  is  an  abrupt  elevation  of  the  mucous  membrane 
and  subjacent  tissue,  which  forms  a  ridge  three-fourths  of  an  inch  in 
length,  and  which  gradually  subsides  as  it  approaches  the  membranous 
lu'ethra.  This  prominence  is  known  as  the  vera  montanum,  crista  urethrcB, 
or  caput  gaUinaginis.  It  contains  erectile  tissue,  connected  with  that  of 
the  corpus  spongiosum,  and  is  adapted  to  assist  in  the  closure  of  the  urethra 
at  this  point,  and  prevent  the  passage  backwards  of  the  semen  during 
coitus.  Directly  in  front  of  the  summit  of  the  veru  montanum,  is  a  small 
sac  or  pouch,  three  or  four  lines  in  depth,  which  is  called  the  "  sinus  pocu- 
laris,"  and  also,  from  its  probable  homology  to  the  womb,  the  "  uterus 
masculinus."^  Tlie  ejaculatory  ducts  traverse  the  walls  of  this  cavity  and 
open  upon  its  margin.  On  each  side  of  the  veru  is  a  depression  called  the 
"  prostatic  sinus,"  in  which  are  found  the  orifices  of  the  prostatic  ducts 
from  twenty  to  thirty  in  number. 

The  memhranous  urethra  extends  from  the  ai)ex  of  the  i)rostate  to  the 

'  The  most  recent  philosophical  anatomists  confirm  tlie  homology  between  the 
prostatic  vesicle  and  the  uterus.  For  an  able  resume  of  this  subject,  see  Simpson, 
Obstetric  Memoirs  and  Contributions,  vol.  ii,  p.  294.     Philadelphia,  1856. 


ANATOMICAL    CONSIDERATIONS. 


251 


Fig.  49. 


Couptl's   GUni, 


bulb,  and  is  nearly  or  wholly  included  within  the  two  layers  of  the  deep 
perineal  fascia.  It  is  about  three-fourths  of  an  inch  in  length  on  its  upper, 
but  is  shorter  on  its  lower  surface,  owing  to  the  encroachment  of  the  bulb 
upon  the  latter.  It  is  narrower  than  any  other  part  of  the  urethra,  except 
the  meatus,  and  in  consequence  of  the  greater  development  and  number  of 
muscular  tissues  surrounding  it,  pos- 
sesses in  a  higher  degree  the  power  of 
contraction.  This  characteristic  has 
led  some  authors  to  give  it  the  name 
of  the  "  muscular  region"  of  the 
urethra. 

The  spongy  iirethra,  inclosed  in  the 
erectile  tissue  of  the  corpus  spongio- 
sum, varies  in  lenjith  according  to  the 
degree  of  turgescence  of  the  penis ;  in 
a  state  of  relaxation,  it  usually  mea- 
sures about  live  inches ;  during  erec- 
tion it  may  attain  seven  or  eight. 
The  posterior  portion  of  this  region  is 
somewhat  dilated,  especially  on  its 
inferior  aspect,  and  has  received  the 
name  of  "  the  sinus  of  the  bidb."  The 
term  "  bulbous  portion"  is  also  applied 
to  the  posterior  inch  of  the  spongy 
urethra.  The  ducts  of  Cowper's 
glands  open  near  its  centre.  Besides 
being  somewhat  dilated,  the  sinus  of 
the  bulb  is  extremely  dilatable.  This 
may  be  shown  by  two  casts  of  the 
urethra  in  fusible  metal,  the  one  taken 
while  the  canal  is  simply  filled,  the 
other  while  it  is  forcibly  distended  by 
the  metal.  The  difference  in  the  size 
of  tlie  part  corresponding  to  the  bulb 
Avill  exhibit  the  dilatability  of  which  it 
is  susceptible.  Anterior  to  its  sinus, 
the  spongy  portion  maintains  a  nearly 
uniform  diameter  until  within  about 
an  inch  of  the  meatus,  where  it  again 
enlarges  and  forms  the  "fossa  navicu- 
larig."  Lastly,  the  external  orifice  or 
"  meatus"  is  a  narrow  vertical  slit, 
which  is  generally  the  most  contracted  part  of  the  wliole  canal.  In  some 
instances,  however,  the  smallest  diameter  is  found  about  a  quarter  of  an 
inch  within  the  meatus,  where  it  can  of  course  be  seen. 

The  mucous  membrane  lining  these  various  regions  is  continuous  poste- 
riorly with  that  of  the   bladder,  and  anteriorly  with  the  covering  of  the 


Ortfice!'  ./  ^ucU. 


The  bladder  and  urethra  laid  open.     Scea 
from  above.     (After  Gray.) 


252 


STRICTURE    OF    THE    URETHRA. 


Lacunii  magna. 


glans  penis.  It  is  very  delicate  in  its  structure,  and  abundantly  supplied 
with  bloodvessels  and  nerves,  Avhich  render  it  highly  vascular  and  sensi- 
tive. Numerous  glands  ("glands  of  Littre") 
racemose  in  their  structure,^  are  found  in  the 
spongy  and  membranous,  and  mucous  follicles 
in  the  prostatic  region,  the  secretion  from  all 
of  which  constantly  lubricates  the  passage. 
Fossae  or  lacunar  of  the  mucous  membrane, 
apparently  destitute  of  glandular  structure, 
are  also  found  upon  the  upper,  and  more  nu- 
merously upon  the  lower  surface  of  the  urethra. 
They  may  sometimes  be  traced  for  nearly  half 
an  inch  beneath  the  lining  membrane,  and 
their  mouths  are  commonly  directed  forwards. 
One,  lai'gor  than  the  rest,  and  called  the 
"lacuna  magna,"  is  situated  on  the  upper 
aspect  of  the  canal,  from  half  an  inch  to  an 
inch  posterior  to  the  meatus.  These  lacunjB, 
especially  when  dilated  by  long-continued  in- 
flammation, may  obstruct  the  passage  of  a 
sound  and  lead  to  the  formation  of  false  pas- 
sages. The  urethral  mucous  membrane  is 
covered  with  the  cylindrical  form  of  epithelium.  Except  in  the  prostatic 
region,  this  membrane  is  arranged  in  longitudinal  folds,  which  are  gene- 
rally in  contact  and  close  the  canal,  the  latter  appearing  on  a  transverse 
section  of  the  penis  as  a  mere  star  or  split. 

According  to  Mr.  Thompson,  the  rugae  of  the  mucous  membrane  "  ap- 
pear to  be  connected  with  the  existence  of  numerous  long  and  slender 
bands  of  fibrous  tissue,  which  are  seen  lying  immediately  beneath  the 
mucous  membrane,  for  the  most  part  in  a  longitudinal  direction.  In  the 
bulbous  and  membranous  portions  they  are  extremely  delicate,  constitut- 
ing these  the  weakest  parts  of  the  urethral  wall,  a  fact  worthy  of  remem- 
brance in  connection  with  the  use  of  instruments."  In  the  bulbous  region 
the  danger  of  doing  violence  is  increased  by  the  dilatability  of  the  passage, 
and  by  the  presence  of  the  firm  anterior  layer  of  perineal  fascia  just  be- 
yond it. 

The  dimensions  and  direction  of  the  urethra,  taken  as  a  whole,  will  be 
better  appreciated  after  considering  other  tissues  which  surround  it. 

The  urethra  is  invested  by  "  unstriped,  organic  or  involuntary"  muscular 
fibres,  which  vary  very  much  in  their  abundance  and  their  arrangement 
in  different  parts  of  the  canal.  These  fibres  in  the  prostatic  urethra  are 
both  longitudinal  and  circular,  the  latter  layer  being  nearly  half  an  inch 
thick  near  the  neck  of  the  bladder,  and  gradually  diminishing  towards  the 
apex  of  the  prostate.     It  has  been  called  by  Ilenle  the  sphincter  vesicce 


'  KoLLiKER,  Manual  of  Human   Histology,  published   by  the   Sydenham   Soc, 
vol.  ii,  p.  236. 


DEEP    PERINEAL    FASCIA.  253 

intermis.  External  to  this  layer  is  another,  called  the  sphincter  vesicce 
externus,  which  is  most  developed  near  the  apex  of  the  prostate,  where  it 
is  continuous  with  the  compressor  ui-ethra;  muscle. 

In  the  membranous  urethra  is  found  a  layer  of  unstriped  fibres  arranged 
circularly,  and  this  portion  of  the  canal  is  also  invested  by  the  striated 
fibres  of  the  compressor  urethrte  muscle. 

In  the  spongy  urethra,  there  are  no  circular  fibres  except  in  the  poste- 
rior portion  of  the  bulb.  There  are  a  few  unstriped  longitudinal  fibres, 
which  are  either  scattered  or  which  form  only  a  broken  layer.  It  thus 
appears,  on  anatomical  grounds,  that  spasmodic  stricture  cannot  exist  an- 
teriorly to  the  deepest  portion  of  the  bulb. 

The  corpus  sponffiosum  is  dilated  at  its  posterior  extremity  where  it 
forms  the  bulb.  It  terminates  anteriorly  in  an  expansion,  called  the 
•'  glans  penis ;"  while  a  thin  layer  of  erectile  tissue  is  continued  back- 
wards around  the  membranous  portion  of  the  urethra  and  extends  into  the 
veru  montanum  of  the  prostate. 

The  coi-pus  spongiosum  consists  of  a  vast  number  of  venous  sinuses, 
communicating  with  each  other  in  all  dii'ections.  Its  great  vascularity 
explains  the  hemorrhage  which  is  liable  to  ensue,  when  the  spongy  portion 
of  the  urethra  is  divided  by  the  knife  of  the  surgeon  or  accidentally 
wounded.  This  occurrence,  however,  is  less  likely  to  take  place,  when  an 
incision  is  confined  to  the  mesial  line  and  made  in  an  upward  direction, 
since  the  amount  of  vascular  tissue  is  much  less  above  than  below  the 
urethra.  This  will  be  shown  by  diagrammatic  sections  of  the  penis,  when 
we  come  to  speak  of  internal  urethrotomy. 

The  corpora  cavernosa  are  tAvo  in  number.  Arising  in  front  of  the 
tuber  ischii,  and  intimately  united  to  the  periosteum  covering  the  rami  of 
the  ischium  and  pubis,  the  two  unite  in  front  of  the  symphysis,  to  which 
they  are  connected  by  the  suspensory  ligament  cxnd  are  continued  forwards 
as  far  as  the  corona  glandis,  wliere  their  common  extremity  is  capped  by 
the  expansion  of  the  corpus  spongiosum  forming  the  glans.  The  vascular 
connection  between  these  bodies  is  free,  though  little,  if  any,  exists  between 
them  and  the  corpus  spongiosum,  which  lies  in  a  groove  upon  their  under 
surface. 

Deep  Perineal  Fascia — The  triangular  space,  seen  in  the  bony  pelvis 
to  intervene  between  the  pubic  and  ischiatic  rami,  is  occupied  by  a  tense, 
fibrous  septum,  constituting  one  of  the  chief  supports  of  the  pelvic  viscera 
above,  and  known  by  the  various  names  of  "  deep  perineal  fascia,"  "  tri- 
angular ligament  of  the  urethra,"  "  Camper's  ligament,"  ''  middle  perineal 
fascia,"  "  ano-pubic  aponeurosis,"  etc.  This  septum  is  composed  of  two 
layers,  an  inferior  and  a  superior,  separated  by  an  interval  in  which  are 
found  the  membranous  portion  of  the  urethra,  which  necessarily  passes 
through  the  deep  perineal  fascia  to  arrive  at  the  surface,  the  compressor 
urethrie  muscle,  Cowper's  glands  and  ducts,  the  arteries  of  the  bulb,  and 
the  dorsal  vein,  nerve,  and  artery  of  the  penis.  We  might  familiarly  liken 
his  septum  to  a  double  window,  through  which  n  funnel,  representing  the 


254 


STRICTURE    OF    THE    URETHRA. 


urethra,  passes  ;  in  which  case  the  portion  of  the  funnel  contained  between 
the  sashes  would  correspond  to  the  meml)ranous  region. 


Fig.  51. 


Vertical  antero-posterior  section  in  the  inedian  line,  showing  fascise.  (After  Tillanx.)  a,  ante- 
rior or  i.ubio-vesicalcal-de-sac  of  the  peritoneum  6,  urachus.  c,  posterior,  or  recto-vesical cul- 
de-sac  of  the  peritoneum,     d,  pubio-prostatic  ligament.     ^  suspensory  ligament  of  the  poms.    /, 


r'ecto-vesical  cul-de-sac  of  the  peritoneum,    i^,  point  at  which  the  peritoneum  is  reflected  ou  the 
posterior  face  of  the  rectum,     q,  summit  of  the  bladder. 

At  their  apex,  the  two  layers  of  the  deep  perineal  fascia  are  thin  and 
firmly  attached  to  the  sub-pubic  ligament  and  pubic  bones,  they  tlien  pass 
downwards  and  backwards,  and  are  stretched  between  the  pubic  and 
ischiatic  rami.  The  space  between  them  containing  the  important  parts 
already  mentioned,  is  from  half  to  three-fourths  of  an  inch  in  depth.  The 
vena  dorsalis  penis  pierces  the  fascia  half  an  inch,  and  the  uretlira  usually 


SUPERFICIAL    PERINEAL    FASCIA. 


255 


at  about  three-fourths  of  an  inch  below  the  symphysis ;  but,  according  to 
measurements  made  by  Mr.  Thompson,  the  latter  distance  may  vary  from 
seven-eighths  to  an  inch  and  a  quarter;  a  difference  of  some  importance  as 
affecting  the  sub-pubic  curve  of  the  urethra. 

The  superior  (or  deeper)  layer  of  the  triangular  ligament  is  continuous 
with  the  aponeurosis  underlying  the  prostate  gland  (the  prostato-perineal 
fascia).  The  inferior  (or  more  external)  layer,  winding  round  the  poste- 
rior edge  of  the  superficial  transversus  perintei  muscle,  advances  forwards 
and  becomes  continuous  with  the  superficial  perineal  fascia  (Buck's  fascia), 
which  invests  the  penis. 

Ficr.  52. 


Diagram  represpnting  a  horizontal  section  of  the  perinajum,  designed  especially  to  show  the 
arrangement  of  the  deep  perineal  fascia.  (After  Tillaux.)  a.  corpus  cavernosum.  h,  inferior 
layer  of  deep  perineal  fascia,  c,  deep  transverse  perineal  or  Guthrie's  muscle.  (<,  section  of 
urethra,  e.  Cowper's  glands.  /,  superior  layer  of  deep  perineal  fascia,  ^r,  internal  pudic  artery, 
ft,  internal  pudic  nerve,  i,  descending  branch  of  the  ischium,  y,  superficial  fascia,  t,  erector 
penis  orischio-caveruosus  muscle.  I,  bulb  of  the  urethra.  ??(,  accelerator  urinie  or  bulbo-caver- 
nosus  muscle,  n,  superficial  fascia,  o,  superficial  perineal  arieiy.  p,  superficial  perineal  nerve. 
q,  skin. 

Siipe^-jicial  Perineal  Fascia. — Strictly  speaking,  there  are  two  layers 
of  this  fascia,  the  superficial  and  deep.  The  former  consists  of  cellulo- 
adipose  tissue,  belonging  to  the  general  integument  of  the  body.  Tlie 
latter  is  aponeurotic  in  its  structure,  and  is  chiefly  important  in  its  relation 
to  the  present  subject.  In  accordance  with  frequent  usage,  it  alone  is  in- 
tended by  the  term  "  superficial  fascia  of  the  perina;um."  This  fibrous 
structure  corresponds  in  its  general  direction  with  the  deep  perineal  fascia 
just  described,  but  is  situated  upon  a  more  external  plane  ;  behind  the  trans- 
versus perinaji  muscle  it  is  reflected  upon  itself  and,  as  already  stated,  be- 
comes continuous  with  the  anterior  layer  of  the  triangular  ligament. 

This  reflection  of  the  fascia,  corresponding  to  the  bi-ischiatic  line,  forms 
a  line  of  demarcation  between  the  anal  portion  of  the  perinaium  behind  and 
the  urethral  portion  in  front.  Purulent  collections  generally  respect  this 
limit,  so  that,  in  the  absence  of  other  data,  we  may  know  with  great  cer- 
tainty wliether  a  perineal  fistula  i)roceeds  from  one  or  the  otlier  of  the.se 
portions.  Anal  and  rectal  fistulie  are  situated  behind  the  line  and  uretliral 
fistula)  in  front.     (Tillaux.) 


256 


STRICTURE    OF    THE    URETHRA. 


At  the  sides  the  superficial  perineal  fascia  is  attached  to  tlie  rami  of  the 
pubic  and  ischiatic  bones.  In  front  it  is  continued  on  to  the  penis  and 
sending  off  a  layer  which  separates  the  corpora  cavernosa  from  the  corpus 
spongiosum  completely  surrounds  this  organ  up  to  the  base  of  the  glans. 


Buck's  fascia.  (After  Buck.)  A.  The  corpus  cavernosum,  enucleated  from  the  sheath.  B.  The 
sheath,  split  up  to  the  suspensory  ligament,  of  whose  anterior  layer  it  is  a  coutiauation.  G.  The 
relations  of  the  sheath  to  the  corpus  spongiosum  urethrse,  one  layer  of  the  fascia  passing  above 
it,  and  the  other  below  it.  D.  Its  relations  to  the  glans  penis,  to  which  the  sheath  adheres  insep- 
arably by  its  outer  surface,  while  by  its  inner  surface  it  caps  the  corpus  cavernosum.  E.  The 
dorsal  arteries,  veins,  and  nerves,  raised  with  the  sheath. 

These  relations  of  the  superficial  fascia  to  the  penis  were  first  fully  de- 
scribed in  the  first  volume  of  the  Transactions  of  the  American  Medical 
Association,  by  the  late  Dr.  Gurdon  Buck  of  New  York.  As  this  paper 
is  not  generally  accessible,  and  deserves  to  be  preserved  in  memory  of  the 
distinguished  sui-geon  who  wrote  it,  I  shall  quote  the  greater  part  of  it: — 

"  The  anatomical  structure  in  question  consists  of  a  distinct  membra- 
nous sheath  investing  the  penis  in  the  manner  to  be  described,  and  forming 
a  continuation  of  the  suspensory  ligament  above,  and  of  the  perineal  fascia 
below,  and  will  be  best  understood  by  a  description  of  the  mode  of  dissect- 
ing it. 

"The  penis  and  scrotum  are  to  be  circumscribed  by  an  incision  at  the 
distance  of  three  fingers'  breadth  all  around,  and  crossing  the  perinauim  at 
the  anterior  margin  of  the  sphincter. 


SUPERFICIAL    PERINEAL    FASCIA.  257 

"The  dissection  of  the  skin  and  subjacent  cellular  and  adipose  tissues  is 
to  be  made  towards  the  penis,  on  the  level  of  the  fascia  lata  laterally,  and 
of  the  perineal  fascia  posteriorly,  and  carefully  continued  to  the  body  of 
the  penis,  as  far  as  the  corona  glandis.  By  this  means,  the  penis,  as  well 
as  the  suspensory  ligament,  is  denuded  of  its  loose  movable  investments. 

"An  incision  is  then  to  be  made  along  the  dorsum  of  the  penis  exactly 
in  the  median  line,  splitting  through  the  suspensory  ligament,  and  extend- 
ing forward  to  the  corona,  between  the  dorsal  vessels  and  nerves  that  run 
parallel  on  either  side.  The  adhesions  of  the  sheath  along  the  dorsum  are 
tirm,  and  require  careful  dissection  ;  the  bloodvessels  and  nerves  being  raised 
with  it,  serve  as  a  guide  to  show  tlie  line  of  adhesion, 

"  The  dissection  being  prosecuted  laterally  as  well  as  inferiorly  and  at 
the  extremity,  the  entire  corpus  cavernosum  is  enucleated,  the  muscles  of 
the  perinanmi  being  raised  with  the  sheath.  It  is  now  clearly  seen  that 
the  suspensory  ligament  from  above,  and  the  perineal  fascia  from  below 
and  laterally,  form  one  continuous  membrane  with  the  sheath,  inclosing 
the  corpus  cavernosum  in  its  cavity,  and  embracing  the  corpus  spongiosum 
urethni3  between  two  layers,  one  of  which  passes  above  and  the  other  below 
it.  The  excavated  base  of  the  glans  adheres  inseparably  to  the  outer  sur- 
face of  the  sheath,  while  by  means  of  its  inner  surface,  it  caps  the  summit 
of  the  corpus  cavernosum. 

"Its  adhesions  are  most  firm  at  the  extremity  of  the  corpus  cavernosum, 
along  its  dorsal  surface,  and  at  the  insertions  of  the  erector  and  accelerator 
muscles.  It  is  thickest  around  the  corona,  along  the  dorsal  surface,  and 
where  it  forms  the  suspensory  ligament.  Zones  of  vessels  run  at  regular 
intervals  in  the  direction  of  the  circumference  of  the  penis,  from  the  dorsal 
trunks  to  the  corpus  spongiosum,  between  the  layers  of  the  slieatli.  The 
cavity  formed  by  the  sheath,  and  occupied  by  the  corpus  cavernosum,  is 
limited  posteriorly  by  the  triangular  ligament  (deep  perineal  fascia). 

"  That  portion  which  covers  the  perineal  muscles,  and  has  been  described 
by  authors  under  the  names  of  the  superficial  fascia  of  the  perineum,  in- 
ferior fascia  and  ano-penic  fascia,  arises  laterally  from  the  ascending  rami 
of  the  ischium,  and  descending  of  the  pubis,  as  far  forward  as  the  inferior 
edge  of  the  symphysis,  where  the  two  layers  meet  and  form  the  suspensory 
ligament.  Postei'iorly,  it  is  continued  over  the  transverse  muscle,  and 
iolding  around  its  edges  is  prolonged  upwards  into  the  ischio-rectal  fossa. 

"  It  also  sends  off  from  its  upper  surface  membranous  septa  between  the 
accelerator  muscles  in  the  middle,  and  the  erectors  on  either  side,  to  join 
the  triangular  ligament,  and  thus  forms  the  three  distinct  and  independent 
sheaths  that  are  confounded  anteriorly  with  the  common  sheath  investing 
th^  corpus  cavernosum." 

M.  Jarjavay  afterwards  confirmed  Dr.  Buck's  observations,  and  gave  full 
credit  to  the  "  Chirurgien  de  TAmerique"  for  the  originality  of  his 
discovery.^ 

'  Jarjavay,  Traite  d'auatomie  cliirurgicale,  Paris,  1854,  t.  ii,  p.  57l). 
17 


258  STRICTURE    OP    THE    URETHRA. 

Richet,^  while  agreeing  with  Dr.  Buck  in  the  main,  differs  from  him  in 
some  particulars.  He  states  that  the  posterior  portion  of  this  fascia  is 
quite  loose  and  areolar  upon  the  dorsum,  where  it  cannot  be  distinguished 
from  that  covering  the  pubes;  and  that  thus  a  communication  is  opened  by 
which  inliltrations  of  urine  may  gain  the  sub-integumental  cellular  tissue 
of  the  penis  and  abdomen  without  perforating  the  fascia. 

Pelvic  Fascia The  pelvic  fascia  is,  in  reality,  the  superior  aponeurosis 

of  the  elevator  ani  muscle — a  muscle  which  is  lined  with  an  aponeurosis  on 
either  side  of  it.  This  fascia  is  lost  on  the  sides  of  tlie  pelvis  with  the 
fascia  of  the  obturator  internus  ;  within,  it  is  attached  to  the  rectum  and 
the  lateral  fascia  of  the  prostate.  Although  thin  in  structure,  it  is  generally 
sufficient  to  prevent  purulent  collections  formed  above  it  from  pointing  in 
the  perina^um  and  vice  versa.     (Tillaux.) 

A  knowledge  of  these  fascire,  which  may  be  facilitated  by  a  study  of  the 
accompanying  figures  from  Tillaux,^  is  essential  to  every  surgeon  who  ope- 
rates upon  the  genito-urinary  organs.  Their  practical  bearing  is  so  clearly 
set  forth  by  Tillaux,  that  I  shall  give  it  in  his  own  words  : — 

The  three  fasciai  above  described,  the  superficial  and  deep  perineal  fascia 
and  the  pelvic  fascia,  circumscribe  between  them  two  chambers  or  reservoirs, 
viz.,  one  inferior  and  the  other  superior.  The  first  contains  the  spongy 
portion  of  the  urethra  and  the  corpora  cavernosa,  the  second  the  membra- 
nous and  prostatic  portions  of  the  canal. 

Inferior  Penile  Chamber This  chamber  is  bounded  by  the  super- 
ficial fascia  of  the  perinaaum  below  and  the  deep  fascia  above.  We  have 
seen  that  these  two  fasciaj  are  continuous  with  each  other  at  the  posterior 
edo-e  of  the  transverse  muscle.  Its  shape  has  been  compared  to  that  of 
a  pistol,  the  but-end  of  which  is  below  at  the  bulb. 

This  cliamber  contains  the  bulb  of  the  urethra,  Cowper's  glands,  the 
spongy  portion  of  the  urethra,  and  the  corpora  cavernosa.  It  is  covered 
by  the  skin,  the  superficial  fascia,  and  the  subcutaneous  layer  of  cellulo- 
fatty  tissue. 

It  is  generally  in  this  compartment  that  ruptures  of  the  urethra  take 
place  in  consequence  of  strictures  ;  hence  the  infiltration  does  not  extend, 
in  the  direction  of  the  rectum,  into  the  ischio-rectal  fossa.  It  first  invades 
the  penis,  but  does  not  remain  confined  there  for  a  long  time  ;  it  extends 
to  the  scrotum,  escapes  from  the  chamber  on  a  level  with  the  suspensory 
ligament,  and  reaches  the  pubis  and  the  walls  of  the  abdomen,  which  are 
sometimes  undermined  in  their  totality. 

In  this  compartment,  also,  urinary  tumors  and  urinary  abscesses  are 
developed,  which  are  so  often  the  consequence  of  strictures  of  the  urethra. 
This  accident  should  be  carefully  distinguished  from  infiltration  of  urine. 
The  latter  takes  place  suddenly  in  consequence  of  rupture  of  the  urethra ; 
the  urine  immediately  invades  the  inferior  chamber  without  any  obstacle 

•  RiCHET,  Traite  d'anatomie  medico-chirurgicale,  2e  ed.,  Paris,  18(j0. 
2  Traite  d'anatomie  topograph ique,  etc.,  Paris,  1877. 


SUPERIOR    OR    PROSTATIC    CHAMBER.  259 

to  its  passage,  passes  beyond  its  limits,  extends  to  a  distance,  and  causes 
mortification  of  the  tissues  wherever  it  extends. 

Urinary  abscesses  and  tumors  occur  in  quite  a  different  way.  The  in- 
flammation of  the  urethra,  which  always  exists  behind  a  stricture,  extends 
slowly  to  the  neighboring  tissues.  There  is  thus  gradually  formed  on  the 
inferior  wall  of  the  canal,  a  nodule,  varying  in  size  (possibly  as  large  as  a 
large  hen's  egg),  and  of  extreme  hardness.  This  is  a  urinary  tumor. 
These  tumors  are  also  immovable,  and  in  case  they  fill  the  space  between 
the  two  ischia,  no  line  of  demarcation  separates  them  from  the  osseous 
walls.  They  occupy  exactly  the  median  line,  which  serves  to  distinguish 
them  from  chronic  inflammation  of  one  of  Cowper's  glands. 

If  the  urethra  breaks  after  this  preparatory  work  has  taken  place,  the 
urine  finds  before  it  an  insurmountable  barrier  and  cannot  become  infiltrated ; 
then  we  have  a  urinary  abscess. 

If  pus  forms  within  this  indurated  mass,  its  envelope  is  so  thick  and 
resistent,  that  we  can  never  feel  fluctuation  at  the  outset.  These  abscesses 
should  be  opened  early,  for  fear  that  the  envelope  may  become  perforated 
and  urinary  infiltration  follow.  It  is  often  necessary  to  cut  through  several 
centimetres  of  indurated  tissue  before  reaching  the  cavity. 

Superior  or  Prostatic  Chamber. — The  prostate  is  circumscribed 
by  a  series  of  aponeurotic  planes  which  isolate  it  on  all  sides.  They  are 
above  and  in  front,  the  pubio-vesical  ligaments  or  tendons  of  the  vesical 
muscle,  which  run  into  the  pelvic  fascia ;  behind  and  below,  the  prostato- 
peritoneal  fascia  and  the  superior  layer  of  the  triangular  ligament ;  on  the 
sides,  the  lateral  aponeurosis  of  the  prostate. 

The  jnibio-vesical  liyaments  are  very  resistent,  but  they  do  not  form  a 
continuous  plane.  Between  their  fibres  exist  spaces  traversed  by  large 
veins  coming  from  the  penis;  the  urine  may  follow  the  same- road,  and 
infiltration  is  then  the  more  easy,  since,  in  front  of  the  ligaments,  exists  a 
layer  of  lax  pre-vesical  cellular  tissue. 

The  prosta to-peritoneal  aponeurosis  (Fig.  51,  n)  extends  from  the  cul-de- 
sac  of  tlie  peritona3um  to  the  posterior  edge  of  the  triangular  ligament.  It 
is  continuous  below  with  the  superior  layer  of  this  ligament,  just  as  the 
superficial  fascia  is  continuous  with  the  inferior.  Its  adherence  with  the 
peritonaeum  prevents  this  membrane  fi-om  ascending  into  the  pelvic  cavity 
as  the  bladder  becomes  distended,  and,  on  the  contrary,  makes  it  form  a 
very  deep  cul-de-sac.  It  covers  all  the  posterior  surface  of  the  prostate, 
which  it  thus  se})arates  from  the  rectum.  But  this  layer,  composed  almost 
exclusively  of  smooth  muscular  fibres,  generally  presents  only  feeble  resist- 
ance. It  is  easily  destroyed  and  perforated  by  pus,  as,  for  instance,  in 
suppurative  prostatitis,  and  thus  a  urethro-rectal  fistida  may  form. 

It  is  evident  that,  if  the  posterior  Avail  of  the  prostatic  chamber  gives 
way,  before  any  barrier  has  been  formed  against  infiltration,  the  urine  at 
once  extends  into  tlie  anal  portion  of  the  perinanun,  invades  the  ischio- 
rectal fossa,  completely  isolates  the  rectum,  and  extends  upwards  into  tlie 
pelvic  cavity.     The   penis,  the  scrotum,  and  the  abdominal  wall  are  abso- 


260  STRICTURE    OF    THE    URETHRA. 

lately  intact.  This  dangerous  form  of  infiltration  is  insidious,  and  at  the 
outset  often  recognized  with  difficulty.  It  is  happily  rare,  and  follows 
most  frequently  false  passages  in  the  prostatic  urethra  in  persons  with  a 
middle  lobe  so  enlarged  as  to  obstruct  the  entrance  of  a  catheter. 

The  lateral  aponeurosis  completes  the  prostatic  chamber.  It  is  a  fibrous 
plane  nearly  quadrilateral,  placed  directly  on  each  side  of  the  prostate  in 
such  a  manner  as  to  present  an  internal  and  an  external  face,  a  superior 
and  an  inferior  border.  It  extends  from  before  backwards,  from  the  pubis, 
where  it  is  continuous  with  the  pubio-prostatic  ligaments  and  the  trian- 
gular ligament,  to  the  rectum,  to  the  lateral  walls  of  which  it  is  attached, 
whence  the  name  of  pubio-rectal,  which  has  been  given  it.  From  above 
downwards,  it  occupies  the  space  comprised  between  the  superior  perineal 
fascia  and  the  prostato-peritoneal  aponeurosis,  to  which  it  is  attached. 
Besides  the  prostate,  the  prostatic  chamber  contains  Wilson's  muscle,  and 
especially  a  large  number  of  veins. 

It  is  very  exceptional  to  find  that  the  lateral  aponeuroses  of  the  prostate 
o-ive  way  in  consequence  of  organic  lesions  of  the  urethra,  or  the  violent 
use  of  a  catheter;  but  they  are  readily  cut  in  the  operation  of  lithotomy, 
especially  in  the  lateral  operation.  This  condition  is  fiivorable  to  infiltra- 
tion of  urine,  which  then  takes  place  in  the  anal  portion  of  the  perina^um; 
and  the  sub-peritoneal  cellular  tissue  is  likewise  invaded. 

The  perina3um,  as  we  have  said,  is  divided  into  two  distinct  portions ; 
one  anterior,  the  genito-urinary  ;  the  other  posterior,  the  recto-anal.  This 
division  is  justified  by  the  course  of  infiltrations  of  urine.  Two  great  forms 
of  infiltration  may  occur ;  one  has  for  its  starting  point  the  portion  of  the 
urethra  included  in  the  penile  or  inferior  chamber,  when  the  urine  invades 
the  penis,  the  scrotum,  and,  if  not  arrested  in  time,  the  abdominal  wall; 
the  other  proceeds  from  the  part  of  the  canal  inclosed  in  the  superior  or 
prostatic  chamber ;  the  urine  extends  into  the  rectal  portion  of  the  peri- 
na^um,  fills  the  ischio-rectal  fossa,  gains  the  pelvic  and  often  the  abdominal 
cavity.     This  is  in  accordance  with  fact  and  with  our  knowledge  of  anatomy. 

Dimensions,  Mobility,  and  Direction  of  the  Urethra — Having  considered 
the  separate  portions  of  the  urethra  and  the  various  tissues  which  surround 
it,  we  may  now  regard  it  as  a  unit ;  and  more  especially  with  reference  to 
the  size  and  form  of  instruments  retjuired  in  tlie  treatment  of  stricture. 

The  statements  of  authors  relative  to  the  length  of  tlie  male  urethra  repre- 
sent it  to  be  from  five  and  a  half  to  twelve  inches.  This  discrepancy  may  be 
accounted  for  by  the  different  methods  employed  in  taking  measurements; 
whether  upon  tlie  living  or  dead  subject ;  by  the  amount  of  traction  exer- 
cised upon  the  parts  ;  and,  also,  to  a  certain  extent,  by  an  actual  variation 
in  different  persons.  The  size  of  the  penis  appears  to  have  no  influence 
upon  the  length  of  the  urethra ;  the  latter,  as  shown  by  Sappey's  observa- 
tions,^ often  being  in  an  inverse  ratio  to  the  former.  The  greatest  source 
of  variation  is  found  n\  the  length  of  the  anterior  or  ascending  portion  of 

1  RechercTies  siir  la  conformation  exterieure  et  la  structure  de  I'uietre  de 
rhomme,  Paris,  1854. 


DIMENSIONS    AND    MOBILITY    OF    THE    UREXIIRA.  261 

the  subpubic  curvature,  AVithout  seeking  for  any  absolute  standard,  it  is 
desirable  to  obtain  an  average  which  may  assist  in  determining  the  situa- 
tion of  strictures,  and  afford  useful  information  in  their  treatment ;  and 
after  all  that  has  been  said  by  authors  of  the  variable  length  of  the  urethra 
in  different  individuals,  the  results  of  measurements  are  found  to  be  nearly 
identical,  provided  the  method  of  making  them  be  always  the  same. 

The  length  of  the  urethra  may  be  estimated  during  life  by  means  of  a 
graduated  catheter,  the  flow  of  urine  indicating  when  the  eye  near  its 
point  has  reached  the  vesical  extremity  of  the  canal,  and  care  being  taken 
that  the  penis  is  not  stretched  upon  the  instrument.  After  death,  the 
urethra  and  bladder  may  be  removed  from  the  body,  slit  open  superiorly, 
gently  extended  upon  some  smooth  surface,  allowed  to  contract  by  their 
own  elasticity,  and  then  measured  with  a  tape.  Attempts  have  also  been 
made  to  ascertain  the  length  of  the  urethra  by  casts  of  the  canal  in  fusible 
metal ;  but  the  two  methods  just  mentioned  are  far  more  reliable. 

According  to  the  careful  and  minute  observations  of  Mr.  Tliompson  and 
Mr.  Briggs,  the  results  of  measurements  thus  taken  during  life  and  after 
death  are  not  identical ;  by  the  former,  the  avei'age  length  is  found  to  be 
seven  and  one-half  inches  ;'  by  the  latter,  eight  and  one-half.  This  differ- 
ence is  constant,  and  may  readily  be  accounted  for  by  the  different  condi- 
tions nnder  which  the  measurements  are  taken.  It  is  worthy  of  remem- 
brance, "  since  all  accurate  researches  into  the  pathological  anatomy  of 
stricture  are,  of  necessity,  confined  to  an  observation  of  the  parts  after 
death,  while,  in  relation  to  treatment,  the  measurement  during  life  is  that 
which  alone  must  be  remembered."'^ 

The  urethra  cannot  be  said  to  have  any  fixed  and  absolute  diameter, 
since  its  walls  admit  of  greater  or  less  expansion  according  to  the  amount 
offeree  exerted  upon  them.  A  No.  12  catheter  or  sound  of  the  English 
scale  rarely  fails  to  pass  with  ease,  if  the  pa,rts  be  healthy  ;  and  not  unfre- 
quently  No.  lo  will  pass  without  difficulty. 

It  is  more  important  to  be  familiar  witli  the  relative  than  witli  the  actual 
diameters  of  the  different  portions  of  the  canal.  The  external  orifice  or 
meatus  is  almost  invariably  the  most  contracted  part;  so  that  whatever 
instrument  fairly  enters  the  urethra  will  pass  tlirough  it,  if  no  obstruction 
exists.  Another  im[)ortant  inference  from  this  fact  is,  that  to  restore  to 
its  original  calibre  by  dilatation  one  of  the  deeper  portions  of  the  urethra 
contracted  by  stricture,  the  meatus  must  be  enlarged,  which  can  generally 
be  effected  only  by  incision.  The  next  narrowest  point  of  the  canal  is  at 
the  junction  of  the  bulbous  and  membranous  regions  ;  while  tlie  middle  of 
the  jtrostatic  portion,  and  the  sinus  of  the  bulb  are  the  widest. 

Xhe  degree  of  mobility  of  different  portions  of  the  in-ethra  is  chiefly  in- 
fluenced by  the  attachments  of  the  neighboring  fasciie.     The  anterior  part 

'  Leroy  d'Etiollcs  oV)taiu(Hl  an  average  of  (?iglit  inclies  from  one.  hundred  niea- 
suroments  during  life,  by  nx-ans  of  a  graduated  gum-elastic  souml.  {Dca  rilri- 
cissomcut  lie  Vnritre,  etc.,  Paris,  p.  5.) 

2  TiioMi'Sox,  op.  cit.,  p.  4. 


262 


STRICTURE    OF    THE    URETHRA, 


of  the  penis  is  free,  and  capable,  in  a  flaccid  condition,  of  assuming  almost 
any  position  ;  in  its  posterior  third,  however,  this  organ  is  connected  with 
the  symphysis,  by  means  of  the  suspensory  ligament ;  with  the  ischiatic  and 
pubic  rami,  by  the  crura  of  the  corpora  cavernosa,  and  with  the  anterior 
layer  of  the  deep  perineal  fascia,  by  means  of  the  bulb  ;  the  spongy  urethra 
may,  therefore,  be  said  to  be  fixed  in  proportion  as  it  approaches  the  mem- 
branous region.  The  membranous  region  is  the  least  movable  of  all,  owing 
to  its  firm  connection  with  the  pelvis  by  means  of  the  two  layers  of  deep 
perineal  fascia.  The  prostatic  urethra  is  susceptible  of  some  slight  change 
of  position,  dependent  upon  the  action  of  the  anterior  fibres  of  the  levator 
ani,  and  the  amount  of  urine  in  the  bladder. 

In  a  flaccid  condition  of  the  penis,  the  urethra  has  two  curves :  the  first 
confined  to  the  anterior,  the  second  to  the  deeper  portion  of  the  canal. 
The  former  is  simply  due  to  the  dependent  position  of  the  anterior  part  of 
the  organ,  and  is  effaced  in  a  state  of  erection  or  when  the  penis  is  ele- 
vated to  an  angle  of  about  60^  with  the  body.     The  latter  may  be  called 

Fig.  54. 


Prep  !**« 

A'ertical  section  of  bladder,  penis,  and  urethra.     (Alter  Gray.) 


the  sul)-pubic  curve,  from  its  position  beneath  the  symphysis.  Unless  some 
degree  of  force  be  used  to  straighten  the  canal,  this  curve  is  permanent, 
and  a  knowledge  of  its  direction  is  essential  in  determining  the  proper 
form  of  instruments  and  the  manner  of  their  introduction. 


STRICTURES.  263 

The  sub-pubic  curve  commences  an  inch  and  a  half  anterior  to  the  bulb, 
attains  its  lowest  point,  when  the  body  is  in  the  upriglit  position,  nearly 
opposite  the  anterior  layer  of  the  deep  perineal  fascia,  and  finally  ascends 
through  the  membranous  and  prostatic  regions.  According  to  the  obser- 
vations of  Mr.  Thompson  and  Mr.  Briggs,  it  "  forms  an  arc  of  a  circle 
three  inches  and  a  quarter  in  diameter ;  the  chord  of  the  arc  being  two 
inches  and  three-quarters,  or  rather  less  than  one-third  of  the  circum- 
ference." Mr.  Thompson  states  that  he  has  often  found  it  more  acute  in 
spare  men ;  and  in  the  corpulent,  more  obtuse ;  that  traction  of  the  abdomi- 
nal muscles  exercised  through  the  suspensory  ligament  may  also  render  it 
more  abrupt,  whence  the  advantage  of  raising  the  shoulders  when  perform- 
ing catheterization  upon  patients  in  the  recumbent  posture.  The  elevation 
of  the  bladder  above  the  pubes  in  children,  and  the  enlargement  of  the 
prostate  so  common  in  old  men,  also  effect  a  change  in  the  direction  of  the 
sub-pubic  curve  from  its  usual  adult  standard,  and  require  therefore  a 
corresponding  variation  in  the  form  of  instruments.  Swellings  and  ab- 
scesses about  the  lower  extremity  of  the  rectum,  large  hemorrhoidal 
tumors,  and  various  other  circumstances  may  also  operate  in  a  greater  or 
less  degree  to  cause  some  change  in  the  direction  of  this  curve. 

Strictures. 

Strictures  may  be  briefly  classified  as  Spasmodic  and  Permaxext  or 
Organic. 

Spasmodic  Stricture — The  chief  element  of  a  spasmodic  stricture  is 
muscular  spasm,  with  which  is  usually  associated  more  or  less  congestion. 
Either  of  these  may  exist  alone;  commonly  both  are  combined. 

Many  of  the  older  writers  on  venereal  diseases,  as  Charles  Bell,  denied 
the  influence  of  spasm,  except  perhaps  in  the  membranous  region,  to  which 
their  knowledge  of  any  muscular  tissue  surrounding  the  urethra  was  mainly 
confined.  The  subsequent  discov.ery  by  Kolliker  and  Hancock  of  organic 
muscular  fibres  about  the  canal  has  shown  the  possibility,  and,  reasoning 
from  analogy,  the  probability,  that  spasmodic  contraction  may  take  place 
in  any  {(art  of  the  uretlira,  where  these  fibres  are  circular;  in  otlier  words, 
witliin  the  limits  already  defined.     (See  page  253.) 

The  exciting  cause  of  spasm  is  some  impression  upon  the  sentient  nerves, 
transmitted  to  a  nervous  centre,  and  returned  through  motor  fibres,  tex*mi- 
nating  in  either  voluntary  or  involuntary  muscles.  In  the  urethra,  spasmo- 
dic ai;tion,  sulUcient  to  produce  stricture,  may  take  place  in  the  submucous 
layer  of  organic  fibres  ;  or,  in  the  membranous  region,  in  the  striped  fibres 
of , the  compressor  urethraj  ;  iinA,  perhajis,  to  a  less  extent,  in  those  of  the 
acceleratores  in  the  spongy  region. 

While  [)erforming  catheterization  upon  irritable  su1)jects,  it  has  occasion- 
ally been  observed  by  nearly  every  surgeon,  that  the  instrument  is  grasped 
and  temporarily  held  by  the  urethral  walls,  even  when  the  canal  is  free 
from  permanent  obstruction.     In  this  case,  the  sound,  or  catheter,  acts  as 


264  STRICTURE    or    THE    URETHRA. 

a  foreign  body,  and  the  irritation  which  it  produces  is  followed  by  con- 
traction in  accordance  with  the  familiar  laws  of  reflex  action. 

In  other  cases,  the  eccentric  irritation  is  caused  by  laceration,  abrasion, 
or  a  wound  of  the  lining  membrane,  such  as  may  ensue  from  the  rough 
use  of  a  catheter,  or  other  surgical  instrument.  This,  of  itself,  may  excite 
spasm;  or  the  same  may  be  induced  by  contact  of  urine  with  the  raw 
surface. 

Striking  examples  of  spasmodic  stricture  are  also  met  with  as  the  result 
of  irritation  about  the  rectum,  excited  by  the  presence  of  a  tapeworm, 
ascai'ides,  htemon-hoids,  fissure  of  the  anus,  fecal  accumulation ;  or  by 
operations  upon  this  part,  especially  the  ligature  of  piles.  Sir  Benjamin 
Brodie^  met  with  a  case  of  spasmodic  stricture,  in  which  the  spasm  was 
intermittent,  recurring  every  twenty-four  or  forty-eight  hours,  and  which 
was  finally  cured  by  quinine  after  the  failure  of  other  means. 

Among  other  causes  of  spasm,  are  the  presence  of  a  stone  in  the  bladder, 
or  urethra  ;  organic  stricture  of  this  canal ;  immoderate  sexual  intercourse  ; 
the  free  use  of  alcoholic  stimulants ;  long  retention  of  tlie  urine  ;  horse- 
back exercise;  digestive  derangements;  exposure  to  sudden  changes  of 
temperature,  and  mental  emotion. 

A  spasmodic  stricture  is  characterized  by  its  short  duration.  It  appears 
suddenly  in  persons  of  delicate  habit,  especially  in  those  who  have  com- 
mitted some  imprudence  in  diet,  and  as  suddenly  disappears.  Explora- 
tion of  the  canal  by  means  of  a  sound  after  the  s[)asm  has  passed,  and 
frequently  during  its  continuance,  shows  that  there  is  no  organic  obstruc- 
tion. Mr.  Smith^  details  a  case  in  which  a  patient,  who  had  suffered  from 
a  violent  attack  of  retention  a  short  time  before,  suddenly  died;  and,  at 
the  post-mortem  examination,  not  the  slightest  contraction  was  found. 

Prof.  Otis  believes  that  a  spasmodic  stricture  due  to  reflex  irritation 
may  exist  continuously  for  years,  even  fifteen  or  twenty  years,  during 
which  time  it  is  nearly  or  wholly  impassable  to  any  instrument,  although 
at  any  moment  it  may  be  made  to  entirely  disappear  by  the  removal  of  the 
source  of  irritation.  He  says  :  "  Deep  organic  uretliral  stricture  is  often 
simulated  by  muscular  spasm,  the  result  of  irritation  caused  by  slight 
anterior  strictures,  even  by  a  slight  contraction  of  the  meatus  urinarius 
alone.  The  great  proportion  of  cases  treated  by  (jradnal  dilatation  are 
treated  for  deep  stricture  lohich  does  not  exist."'^  (The  italics  are  in  the 
original.)  So  far  as  I  know,  such  long-continued  spasm  is  never  met  with 
in  other  muscular  tissues.  Moreover,  I  believe  that  any  spasmodic  stric- 
ture can  be  passed  with  patience  and  suitable  instruments,  and  until  I 
meet  with  a  case  of  the  kind  described  by  Dr.  Otis,  as  I  never  yet  have 
done,  I  cannot  admit  of  spasm  lasting  through  years. 

I  shall  presently  have  occasion,  when  speaking  of  the  seat  of  strictures, 
to  mention  Verneuil's  views  regarding  spasmodic  stricture  at  the  bulbo- 

'  Lond.  M.  Gaz.,  vol.  i,  p.  507. 

2  Henky  Smith,  Stricture  of  the  Urethra,  London,  1857,  p.  23. 

3  Stricture  of  the  Male  Urethra,  1878,  p.  301. 


PERMANENT    OR    ORGANIC    STRICTURE,  265 

membranous  junction,  which  are  of  interest  in  this  connection,  and  are 
quite  similar  to  those  recently  set  forth  by  Dr.  Otis. 

In  the  great  majority  of  cases  which  come  under  the  observation 
of  the  surgeon,  inflammation  and  spasm  are  combined,  and  to  these  is 
added  some  degree  of  permanent  contraction.  A  patient  has  an  organic 
stricture  which  has  given  him  but  little  annoyance,  and  offered  no  serious 
obstacle  to  the  complete  evacuation  of  the  bladder ;  suddenly,  after  freely 
indulging  in  spirits,  or  coitus,  and  retaining  his  urine  for  several  hours,  he 
finds  himself  utterly  unable  to  pass  water.  The  urethra,  partially  con- 
tracted by  organized  deposit  in  and  around  its  walls,  is  entirely  closed  by 
the  supervention  of  congestion  and  spasm,  and  complete  retention  is  the 
result.  Under  appropriate  treatment,  the  congestion  and  spasm  may  be 
subdued,  though  the  organic  stricture  remains  after  their  disappearance. 

Permanent  or  Organic   Stricture The  albuminous  fluid  which 

infiltrates  the  tissues  in  acute  urethritis,  and  which  may  contribute  to  the 
formation  of  congestive  stricture,  is,  in  most  cases,  eventually  absorbed, 
and  the  canal  recovers  its  normal  calibre.  But  under  other  circumstances, 
and  especially  as  a  consequence  of  chronic  inflammation,  products  of  a 
more  plastic  nature  are  thrown  out,  which  become  organized,  exhibit  the 
same  tendency  to  contract  as  adventitious  deposits  in  other  parts  of  the 
body,  and  give  rise  to  permanent  contractions  of  the  canal. 

According  to  the  more  recent  views  of  pathologists,  stricture  is  due  to  a 
proliferation  of  the  elements  of  the  submucous  cellular  tissue  and  not  to  the 
organization  of  any  effused  fluid.  It  is  evident  that  the  diminution  in  the 
calibre  of  the  urethra  is  but  one  of  the  bad  effects  of  stricture  ;  the  normal 
elasticity  of  the  canal  is  lost,  and  the  exei'cise  of  its  function  seriously  in- 
terfered with. 

Organic  stricture  may  be  due  to  traumatism,  as  a  fall  upon  the  perini^um, 
in  which  case  it  is  peculiarly  obstinate  and  not  generally  amenable  to  treat- 
ment by  dilatation.  In  the  anterior  portion  of  the  canal,  it  may  also  have 
arisen  from  the  cicatrization  of  a  chancroid,  or  from  the  specific  induration 
surrounding  a  chancre.  Masturbation  has  also  been  enumerated  among 
the  causes  of  stricture,  but,  as  it  appears  tome,  without  sufficient  evidence.^ 

Seat. — There  are  several  sources  of  error  which  should  be  avoided  in 
attempts  to  determine  the  anatomical  seat  of  strictures  during  life.  These 
are  the  mobility  of  the  stricture  itself,  which  may  often  be  thrust  back  to  a 
considerable  distance  on  the  point  of  an  instrument ;  the  liability  of  the  penis 
to  be  elongated  by  traction  at  the  time  of  taking  the  measurement ;  and  the 
actual  elongation  which  often  ensues  as  a  consequence  of  the  frequent 
handling  which  this  organ  receives  from  persons  suflTering  under  stricture. 
Th(?  great  discrepancy  in  the  stat(;ments  of  authors  as  to  the  most  fre(iuent 
seat  of  this  com[)laint  shows  that  these,  and  i)erliaps  other  sources  of  error 
have  not  been   sufficiently  guarded  against;  and  the  tendency  has  almost 

'  See  a  paper  by  Dr.  Samuel  W.  Gross,  On  sexual  debility  and  impotence,  with 
special  reference  to  masturbation  as  an  exciting  cause  of  stricture,  Med.  and  Surg. 
Reporter,  Pliila.,  May  5,  1877. 


266 


STRICTURE    or    THE    URETHRA. 


invariably  been,  as  shown  by  recent  investigations,  to  assign  to  stricture  a 
seat  posterior  to  its  true  situation. 

Fig.  55. 


The  spongy  portion. 


Tliu  meml)ranons 
portion. 


The  prostatic 
portion. 


Region  No.  III. 


Region  No.  II. 


Region  No.  I. 


"  A  healthy  nrelhra,  eight  inches  and  a  half  in  length,  slit  up  from  the  upper  part,  accurately 
reduced  on  scale  from  a  drawing  made  from  the  oriijinal  while  fresh,  to  half  the  natural  size. 
On  the  left-hand  side  arc  indicated  the  anatomical  divisions  of  tlie  urethra,  and  on  the  right  the 
boundaries  of  the  regions  refeiTi-d  to  in  relation  to  the  locality  of  stricture."     (After  Thompson.) 

Sir  Henry  Thompson  made  a  careful  and  laborious  examination  of  over 
three  hundred  preparations  of  stricture  contained  in  the  chief  museums  of 
Paris,  London,  and  Edinburgh,  and  arrived  at  the  following  conclusions 
as  to  its  site.  He  premises  by  dividing  the  urethra  for  the  sake  of  con- 
venience into  these  three  regions  : — 

I.  The  Sub-pubic  Curvature,  which  comprises  an  inch  of  the  canal 
before,  and  three-quarters  of  an  inch  behind,  the  junction  between  the 
spongy  and  membranous  regions,  tlius  including  the  whole  of  the  mem- 
branous portion. 


SEAT.  2fiT 

II.  The  Centre  of  the  Spongy  Portion,  a  region  extending  from 
the  anterior  limit  of  the  preceding,  to  within  two  inches  and  a  half  of  the 
external  meatus,  and  measuring  therefore  about  two  and  a  half  to  three 
inches  in  length. 

III.  The  External  Orifice,  including  a  distance  of  two  inches 

AND  A  HALF  BEHIND  IT. 

Of  270  preparations,  embracing  320  distinct  strictures,  Mr.  Thompson 
found 

In  region  I         .  .  .  216  or  67  per  cent. 

"       "      II  .  .  .  ol  "   16     "      " 

"      "    III         .         .         .  54  "  17    "      " 

320 

According  to  this  eminent  authority,  the  largest  number  of  strictures  are 
therefore  situated  at  the  sub-pubic  curvature  ;  and  he  would  still  further 
limit  the  most  frequent  locality  to  the  anterior  portion  of  this  region,  since 
he  says  "  that  part  of  the  urethra  which  is  most  frequently  affected  with 
stricture  is  tlie  portion  comprised  in  the  inch  anterior  to  the  junction,  that 
is,  the  posterior  or  bulbous  part  of  the  spongy  portion.  The  liability  of 
this  part  to  stricture  appears  to  diminish  as  it  approaches  the  junction, 
where  it  is  less  common  ;  while  behind,  it  is  very  rare.  Most  rarely  is  a 
stricture  found  so  far. back  as  the  posterior  part  of  the  membranous  por- 
tion."' The  next  most  frequent  situation  of  stricture  is  stated  to  be  the 
external  two  and  a  half  inches,  and  the  least  frequent  the  middle  portion 
of  tlie  spongy  region,  although  the  difference  between  the  two  is  not  very 
great ;  while  botli  are  of  but  small  importance  compared  with  the  anterior 
portion  of  the  bulb. 

Mr.  Walsh'^  and  M.  Mercier^  arrived  at  results  very  similar  to  the 
above. 

On  the  otlier  hand,  in  1866,  M.  Verneuil  read  a  paper  before  the  Ana- 
tomical Society  of  Paris,*  in  which  he  denied  the  frequency  of  organic 
stricture  at  the  bulb  and  at  the  commencement  of  the  membranous  portion  ; 
or  rather  he  maintained  that  in  cases  of  stricture  a  ^iroHS  contraction  is 
almost  always  met  with  at  about  two  and  one-half  inches  from  the  meatus, 
and  tliat  beyond  this,  at  the  depth  of  five  inches,  i.  e.,  at  the  bulbo  mem- 
branous junction,  there  is  constantly  a  second  contraction,  but  only  spas- 
modic and  symptomatic  of  the  former.  "Whenever  there  is  irritation  of 
the  anterior  portion  of  the  urethra,  the  membranous  portion  contracts  and 
arrests  a  sound."  "  Wlienever  a  patient  shows  symptoms  of  urethral  stric- 
ture, one  contraction  exists  in  the  spongy  portion,  a  second  in  tlie  mem- 
branous portion.     The  first   alone  is   fibrous  ;   the   second  spasmodic  and 

'  Op.  cit.,  p.  83. 

•^  Mod.  Press,  Dubl.,  Jan.  23,  1856,  p.  51. 

3  Rochorchos  sur  le  traitement  d.  mal.  d.  voies  urinaires,  1850,  p.   377.     Also 
Bull.  Soc.  anat.  de  I'aris,  1858,  p.  441. 
*  Bull.  Soc.  anat.  de  Paris,  avril,  18(JG,  p.  170. 


268  STRICTURE    OF    THE    URETHRA. 

symptomntic  of  the  first."  Verneuirs  views  are  still  furthei-  developed  in 
an  able  article  by  M.  H.  Folet/  in  which  an  extensive  bibliography  of  the 
opinions  of  dilTerent  authors  on  the  seat  of  stricture  is  given  and  the  fol- 
lowing conclusions  ai-e  arrived  at : — 

1.  Fibrous,  organic  stricture  is  frequent  in  the  spongy  portion  of  the 
urethra,  where  it  is  often  overlooked. 

2.  Organic  stricture  of  the  bulbo-membranous  region,  although  said  to 
be  frequent,  is  rare. 

3.  In  all  cases  of  stricture  of  the  spongy  urethra,  there  exists  a  second 
obstruction  five  inches  from  the  meatus,  at  the  commencement  of  the 
membranous  region.  This  obstruction  is  due  to  muscular  spasm,  and  is 
only  a  symptom  of  the  penile  stricture.  Tlie  latter  (penile)  is  often  slight 
and  incapable  in  itself  of  notably  impeding  micturition.  The  secondary 
spasm  is  the  efficient  cause  of  the  dysuria,  and  constitutes  a  serious  and 
sometimes  invincible  obstacle  to  catheterization. 

4.  The  calibre  of  the  penile  stricture  is  constant,  and  can  be  only  slowly 
and  regularly  dilated.  That  of  the  spasmodic  stricture  is  subject  to  the 
most  sudden  and  capricious  variations  ;  it  may  perhaps  be  easily  passed  in 
the  morning,  and  in  the  evening,  under  the  influence  of  some  irritation,  be 
completely  impassable. 

.5.  In  those  rare  cases  in  which  the  organic  stricture  is  seated  at  the 
bulb,  a  secondary  spasmodic  stricture  exists  none  the  less,  immediately 
behind  it. 

Dr.  Otis,^  whose  views  on  spasmodic  stricture  have  already  been  referred 
to,  is  also  a  firm  believer  in  the  greater  frequency  of  organic  strictures  in 
the  spongy  portion  of  the  urethra.  He  states  that  out  of  258  strictures 
under  his  care,  52  were  in  the  first  quarter  inch  of  the  urethra  ;  G3  in  the 
following  inch,  viz.,  from  :^  to  1^  ;  48  from  1^  to  2\  ;  48  from  2;^  to  3^  ; 
19  from  ^  to  4^  ;  14  from  4|  to  5^ ;  8  from  5^  to  ^  ;  6  from  G^  to  7^. 

These  discrepancies  may,  perhaps,  be  explained,  when  we  consider  the 
two  methods  by  which  the  results  have  been  obtained  :  Sir  Henry  Thomp- 
son and  others  founding  their  observations  upon  post-mortem  specimens, 
and  enumerating  only  such  cases  of  stricture  as  are  apparent  after  death  ; 
Verneuil  and  Dr.  Otis  making  their  examinations  during  life,  and  count- 
ing in  a  large  number  of  slight  contractions,  even  of  the  meatus,  which 
their  opponents  would  not  admit  to  be  strictures  at  all.  Further  and  un- 
biased investigation  is,  however,  necessary  before  this  question  can  be 
regarded  as  settled. 

Stricture  never  occurs  in  the  prostatic  region  of  the  urethra,  at  least 
no  unquestionable  instance  of  the  same  is  to  be  found  recorded. 

Number. — Thompson  states  that  in  most  cases  there  is  only  one  stric- 
ture in  the  same  subject.  Of  267  preparations  examined  by  him,  the 
stricture  was  single  in  226.  Others  have  reported  several  distinct  con- 
tractions.    Hunter^  met  with  six ;  Colot  with  eight ;  and   Ducamp  with 

•  Arch.  gen.  de  med.,  Paris,  avril,  1857,  p.  401. 

*  Op.  cit.,  i>.  97.  ^  Kicord  and  Hunter,  op.  cit.,  p.  1G8. 


FORM. 


269 


Fi°:.  56. 


Fiff.  57. 


Fig.  .16.  Annular  stricture. 

Fig.  07.  Irregular,  or  tortuou.s  stricture.  Posterior  to  the  stricture  in  each  figure  are  seen 
pouches  of  the  mucous  membrane,  formed  by  dilatation  of  the  lacuna;  aud  ducts,  and  capable  of 
entangling  the  point  of  an  instrument.     (After  Thompson.) 


five ;  but  Boyer  never  found  more  than  three,  and  Mr.  Thompson'  never 

more  than  "  three,  or  at  the  most  four."     Civiale^  says  that  when  there 

are  several,  one  of  them  is  almost  always 

situated  in  the  sub-pubic  curve,  and  the  Fig.  58. 

others  between  it  and  the  meatus.    Here 

again    Otis,  with  a  different   method   of 

examination,  is  at  variance  with   other 

authorities,  regarding  multiple  strictures 

in  the  same  person  as  the  rule  and  not 

an  exception.     He  reports   one  case   in 

which  he  found  fourteen.^ 

Form The  form  of  stricture  neces- 
sarily varies  with  the  amount  and  situa- 
tion of  the  fibrinous  deposit  which  pro- 
duces it.  This  may  consist  of  a  few  fibres, 
which  encircle  the  whole  or  a  ])art  of 
the  urethral  circumference,  like  a  thread, 
or  may  form  a  band,  varying  in  extent 
and  thickness.  Tliis  is  the  "  linear  stric- 
ture" of  Mr.  Thompson  and  others  ;  the 
"  bridle  stricture"  of  Cliarles  Bell ;  and 
the  "  valvular  stricture "  of  French 
writers. 


Strictures   near  the  orifice  of   the 
urethra.     (After  Thompson.) 


'  Op.  cit.,  p.  54. 


2  Op.  cit.,  vol.  i,  p.  157. 


3  Op.  cit.,  p.  68. 


270  STRICTURE    OF    THE    URETHRA. 

Where  the  fibrinous  deposit  is  more  extensive,  the  stricture  covers  a 
larger  portion  of  the  urethral  walls.  In  some  instances,  it  is  abrupt  on 
either  side,  like  the  last-mentioned  form,  but  wider ;  as  if  a  whip-cord 
were  tied  externally  to  the  mucous  membrane  ;  this  is  called  an  "annular 
stricture."  If  the  induration  be  more  diffused  around  its  base,  a  section 
of  the  canal  will  resemble  an  hour-glass,  and  the  contraction  receives  the 
name  of  "indurated  annular  stricture."  Again,  stricture  may  involve  the 
canal  to  the  extent  of  half  an  inch  or  several  inches  ;  when  the  passage  is 
often  more  or  less  deviated  from  its  normal  direction,  and  the  stricture  is 
said  to  be  "  irregular  or  tortuous." 

Degree  of  Contraction The  plastic  material  of  stricture   exhibits  a 

constant  tendency  to  contract,  and  become  harder  and  firmer  with  time ; 
it  is  consequently  true,  as  a  general  rule,  that  the  longer  a  stricture  lias 
existed,  the  more  callous  it  is,  and  the  less  susceptible  of  dilatation.  Ex- 
ceptions to  this  law,  however,  sometimes  exist;  and  strictures  of  long 
duration  are  met  with  which  yield  readily,  while  others,  recent  in  their 
origin,  prove  very  obstinate. 

Complete  obliteration  of  the  urethra  may  take  place  as  a  consequence 
of  a  wound  of  the  canal,  sometimes  from  within,  but  more  frequently  from 
without.  In  strictures  other  than  those  of  traumatic  origin,  the  urethral 
w^alls  are  probably  never  completely  fused  together;  although  cases  are 
reported  in  which  fistulous  passages  had  for  a  long  time  turned  tlie  urine 
from  its  normal  channel,  and  in  which,  on  post-mortem  examination,  it 
was  impossible  to  introduce  the  finest  probe  througli  the  contraction,  even 
after  the  external  portion  of  the  penis  had  been  slit  up.^  Instances  of  this 
kind,  however,  are  rare;  in  most  cases,  liowever  great  the  narrowing, 
urine  will  still  find  its  way  out,  though  it  may  be  only  by  a  few  drops  at 
a  time. 

There  has  been  no  little  discussion  of  the  question,  whether  the  urethra, 
when  permeable  to  urine,  is  always  permeable  to  instruments.  The  late 
Mr.  Syme,  of  Edinburgh,  and  also  Mr.  Lister,  asserted,  in  the  earlier 
years  of  their  practice,  that  whenever  any  urine  comes  out  a  catheter  may 
with  patience  and  perseverance  be  got  in  sooner  or  later,  but  they  were 
both  of  tliem  repeatedly  foiled  at  a  later  period  of  their  lives,  and  it  is  safe 
to  say  that  no  surgeon  of  any  considerable  experience  will  maintain  that 
he  has  never  met  with  a  case  of  "impassable  stricture." 

Pathology  op  Stricture. 

In  mild  cases  of  stricture,  the  canal  in  front  of  the  contraction  preserves 
its  normal  dimensions  and  character ;  but  in  severe  and  chronic  cases, 
when  the  flow  of  urine  has  been  much  obstructed,  and  tlic  anterior  portion 
of  the  urethra,  through  continuity  of  tissue,  has  particijjated  in  the  inflam- 
mation which  chiefly  affects  the  part  behind  the  stricture,  it  is  contracted; 
another  condition,  difficult  of  explanation,  is  one  of  dilatation,  which,  in 

'  Thompson,  op.  cit.,  p.  GO-Gl. 


PATHOLOGY    OF    STRICTURE.  2T1 

a  case  described  and  figured  by  Charles  Bell,  was  very  considerable.  In- 
stances in  which  the  urethra  was  ulcerated  in  front  of  the  stricture,  are 
also  given  by  the  same  author. 

Posterior  to  the  stricture,  the  urethra  is  generally  enlarged,  as  a  natural 
consequence  of  the  impediment  to  the  free  evacuation  of  the  bladder.  The 
canal  ultimately  loses  its  elasticity  and  becomes  dilated  so  as  readily  to 
admit  the  finger,  or  even  form  a  pouch  which  may  appear  as  a  fluctuating 
tumor  in  the  perinteum.  The  lacunar  of  the  mucous  membrane  and  the 
orifices  of  the  prostatic  and  ejaculatory  ducts  frequently  participate  in  this 
enlargement;  and  the  septa  between  the  pouches  thus  formed  constitute 
a  network,  chiefly  confined  to  the  floor  and  sides  of  the  canal,  wliich  is 
well  adapted  to  obstruct  the  passage  of  an  instrument  unless  the  point  be 
well  elevated  towards  the  pubes. 

The  mucous  membrane  behind  the  stricture  is  the  seat  of  chronic  in- 
flammation;  it  is  sometimes  contracted  and  puckered;  sometimes  thin 
and  minutely  injected  with  bloodvessels;  the  surface  is  generally  covered 
with  a  layer  of  pasty  exudation,  and  it  is  from  this  source  that  the  gleety 
discharge,  which  is  so  constant  an  attendant  upon  stricture,  is  derived. 
Ulceration  frequently  takes  place,  which  may  be  superficial,  or  which  may 
extend  to  the  deeper  tissues,  producing  large  and  ragged  excavations  of 
the  urethral  walls,  or,  in  rare  instances,  it  may  even  occasion  destruction 
of  the  contracted  portion  of  the  canal. 

Abscess  and  Fistula A  still  more  serious  consequence  of  stricture  is 

the  development  of  abscesses  and  fistulte  in  the  neighborhood  of  the  urethra. 
In  most  cases  the  urethral  mucous  membrane  is  impaired  or  destroyed  at 
one  or  more  points  by  ulceration;  during  the  sti-aining  of  micturition, 
urine,  perhaps  in  a  very  minute  quantity,  escapes  into  the  cellular  tissue ; 
an  abscess  is  formed  which  burrows  in  various  directions,  or  which  opens 
and  establishes  a  fistulous  communication  between  the  external  surface 
and  the  urethra.  In  other  cases  abscesses  are  developed  without  rupture 
of  the  urethral  walls  or  infiltration  of  urine ;  and  they  may  occur  even 
when  the  obstruction  to  the  evacuation  of  the  bladder  is  far  from  complete. 
In  most  cases,  however,  a  communication  is  subsequently  established  by 
the  ulcerative  process.  When  a  urethral  opening  exists,  it  is  generally 
behind  the  contracted  part,  but  sometimes  in  front  of  it.  Tlie  coui'se  taken 
by  urinary  fistula;  is  often  veiy  erratic ;  they  may  open  into  the  rectum, 
upon  the  perina^um,  upon  the  surface  of  the  scrotum,  upon  the  abdomen, 
even  as  high  as  the  umbilicus,  or  upon  the  thighs  or  nates. 

These  abnormal  passages  rarely  have  more  tlian  one  opening  into  the 
urethra,  but  very  frequently  a  number  upon  the  external  surface :  in  one 
ca^e,  seen  by  Civiale,  the  latter  amounted  to  no  less  than  fifty-two.^  Their 
internal  surface  becomes  lined  with  adventitious  tissue,  which  bears  a  very 
close  resemblance  to  mucous  membrane,  but  is  destitute  of  glands  and 
follicles;  it  is  organized,  well  supplied  with  nerves  and  bloodvessels,  and 
constantly  secretes  a  muco-jjurulent  fluid.     Calculous  matter  is  deposited 

•  Op.  cit.,  vol.  i,  p.  539. 


272  STRICTURE    OF    THE    URETHRA. 

in  fine  particles  or  in  larger  masses,  resembling  mortar,  upon  the  walls, 
and  more  particularly  near  the  orifices  or  in  some  blind  pouch  opening 
into  the  passage. 

Deposition  of  similar  matter  often  takes  place  in  the  dilated  sinuses  of 
the  prostate,  and  this  gland  may  become  infiamed,  and  abscesses  form  in 
its  substance. 

Bladder The  vesical  walls  become  hypertrophied,  as  a  consequence 

of  the  obstruction  to  the  flow  of  urine  and  the  additional  force  requisite 
for  its  expulsion  induced  by  stricture.  This  hypertrophy  chiefly  affects 
the  muscular  layer,  but  does  not  wholly  spare  the  areolar  tissue,  which  is 
somewhat  thickened  and  increased  in  density.  The  walls  of  the  bladder 
may  attain  five  or  six  times  their  normal  thickness,  and  measure  from  half 
an  inch  to  an  inch  in  thickness.  The  developed  fasciculi  of  muscular 
fibres  form  prominent  ridges  upon  the  mucous  surface,  and  have  been 
aptly  compared  to  the  columnar  carnete  of  the  heart's  cavities.  Frequent 
and  violent  expulsory  efforts  cause  protrusion  of  the  mucous  membrane 
between  these  columns,  and  pouches  are  formed,  which,  small  at  first,  may 
gradually  increase  in  size  until  they  equal  or  excel  the  dimensions  of  the 
bladder  itself. 

On  post-mortem  examination  the  mucous  membrane  of  the  bladder  is 
found  to  be  thickened,  soft  and  pvdpy,  and  much  congested  in  patches ; 
its  color  is  heightened  and  generally  of  a  dark-red  hue,  its  surface  is 
smeared  with  slimy  mucus,  which,  when  mingled  with  the  urine,  may 
obstruct  the  narrow  orifice  of  the  stricture  ;  scattered  over  it  is  a  quantity 
of  fine  calculous  matter,  or  it  is  covered  with  lymph,  sometimes  in  small 
patches,  at  others,  in  layers  of  considerable  extent. 

The  irritability  of  the  bladder  excites  to  frequent  acts  of  micturition, 
and  the  capacity  of  this  viscus  is  eventually  much  diminished.  Instances 
are  recorded  in  which  it  would  not  contain  more  than  an  ounce,  or  even 
half  an  ounce,  of  fluid. 

Ureters  and  Kidneys As  a  stricture  obstructs  the  exit  of  urine  from 

the  bladder,  so  it  cannot  but  impede  the  passage  of  fluid  into  it ;  conse- 
quently we  find  changes  similar  to  those  already  described  in  the  ureters 
and  kidneys.  The  former  are  often  so  dilated  tliat  they  will  admit  the 
finger  or  thumb,  and  in  some  instances,  have  been  mistaken  for  a  portion 
of  the  small  intestine  ;  their  parietes  are  thickened,  and  lymphy  deposits, 
and  other  evidences  of  chronic  inflammation  are  found  upon  their  internal 
surface.  The  kidneys  may  participate  in  these  lesions ;  the  pelvis,  infun- 
dibvda,  and  calices,  are  distended ;  the  medullary  tissue  of  the  organ  is 
atrophied  under  the  pressure  to  which  it  is  subjected,  and  enormous  reser- 
voirs may  be  formed,  capable  of  containing  five,  ten,  and  in  one  instance, 
observed  by  Sir  Henry  Thompson,  twenty  ounces. 

Genital  Organs Stricture  is  not  unfrequently  attended  with  hyper- 
trophy and  induration  of  the  penis,  and  tumefaction  and  ajdema  of  the 
prepuce. 

The  ejaculatory  ducts  may  be  dilated  ;  their  walls,  and  those  of  the 
vesicular  seminales,  inflamed  and  thickened ;  and  their  cavities  contain 


SYMPTOMS    OF    STRICTURE.  273 

pus,  and  other  products  of  inflammation.  There  is  often  considerable 
irritability  of  the  testicle,  and  attacks  of  epididymitis  sometimes  occur, 
especially  after  the  use  of  instruments  within  the  urethra. 

It  is  evident  from  a  consideration  of  the  organic  lesions  which  stricture 
induces  in  the  bladder,  ureters,  and  kidneys,  that  the  secretion  of  urine 
must  be  seriously  interfered  with,  and  the  perfect  elimination  of  eflPete 
matter  consequently  prevented  ;  and  it  is  also  probable  that  more  or  less 
noxious  material  is  absorbed  from  the  partially  decomposed  urine  which 
collects  in  the  bladder  and  elsewhere.  The  inevitable  eflfect  of  this  upon 
the  system  at  large,  and  especially  upon  the  nervous  centres,  is  too  well 
known  to  require  explanation. 

Symptoms  of  Stricture. 

One  of  the  earliest  symptoms  of  organic  stricture  is  generally  a  gleety 
discharge  from  the  urethra.  If  the  contraction  of  the  canal  has  imme- 
diately succeeded  an  attack  of  gonorrhoea,  the  urethra  may  never  have 
recovered  its  normal  condition  since  the  acute  symptoms  were  present ; 
but  in  some  instances  all  traces  of  muco-purulent  matter  had  entirely  dis- 
appeared, when  suddenly,  perhaps  after  some  excess,  the  linen  is  found 
again  stained,  or  the  lips  of  the  meatus  adherent.  This  discharge  is  not 
a  constant  symptom  of  stricture,  but  is  present  in  the  great  majority  of 
cases.  It  is  chiefly  derived  from  the  contracted  portion  of  the  canal,  and 
the  parts  lying  directly  behind  it. 

Another  early  symptom,  and  sometimes  the  first  which  attracts  the 
notice  of  the  patient,  is  a  gradual  diminution  of  the  power  over  his  bladder. 
He  is  not  able  to  retain  his  water  as  long  as  usual,  and  a  desire  to  urinate 
calls  him  up  several  times  during  the  night.  The  stream,  moreover,  is 
diminished  in  fulness,  is  projected  with  less  force  than  natural,  and  may 
be  variously  distorted  ;  sometimes  it  is  flattened,  at  other  times  spiral 
like  a  corkscrew,  forked,  or  divided  into  two  or  more  portions  which  di- 
verge from  the  meatus ;  or,  at  the  same  time  that  a  small  stream  issues 
from  the  canal,  a  portion  falls  in  drops  at  his  feet  ;  he  is  obliged  to  take 
special  care  to  avoid  soiling  his  shoes  and  clothes ;  and  finally,  when  he 
supposes  the  act  fully  accomplished,  a  few  drops  dribble  away,  and  wet  his 
person  and  his  clothing.  The  above  symptoms  cannot,  however,  be  re- 
garded as  pathognomonic  of  organic  stricture,  since  they  may  be  produced 
by  otiier  causes,  as  the  presence  of  inspissated  mucus  in  the  canal,  spas- 
modic contraction,  calculi,  irregular  action  of  the  bladder,  etc. 

At  the  same  time,  each  passage  of  the  urine  may  be  attended  with  pain  and 
disagreeable  sensations,  varying  in  intensity,  position,  and  character.  Most 
frequently  there  is  a  sense  of  dull  aching  in  the  perineum,  back,  and  loins, 
or  in  the  glans  penis  ;  often  pain  of  a  sharper  character  is  felt  in  the 
course  of  the  urethra  or  at  the  neck  of  the  bladder,  or  follows  the  course 
of  the  spermatic  cord,  and  is  most  severe  in  the  groins  and  testicles,  wliile 
sometimes  it  shoots  down  the  thighs.  Another  frequent  seat  of  pain  is 
18 


274  STRICTURE    OF    THE    URETHRA. 

behind  the  pubes,  where  it  is  probably  due  to  some  degree  of  inflammation 
of  the  bladder. 

As  the  disease  progresses,  all  the  above  symptoms  are  aggravated  ;  and 
the  urgency  of  micturition,  especially,  is  much  increased.  Frequently, 
the  patient  is  almost  wholly  deprived  of  sleep  by  repeated  calls  to  urinate, 
and  the  length  of  time  which  this  act  requires.  In  aggravated  cases,  the 
urine  dribbles  away  in  small  quantities,  while  the  patient  is  asleep,  or  with- 
out his  consciousness  during  the  day.  This  has  sometimes  been  mistaken 
for  incontinence  of  urine;  whereas  it  is  almost  invariably  due  to  disten- 
tion of  the  contracted  bladder  and  overflow  of  its  contents.  The  urine 
also  undergoes  certain  changes  in  consequence  of  its  retention  and  partial 
decomposition,  and  the  vesical  inflammation  which  is  thereby  excited. 
These  have  already  been  mentioned  in  the  chapter  on  cystitis. 

Hcematuria,  which,  however,  is  seldom  excessive,  sometimes  occurs  in 
connection  with  stricture,  and  is  most  frequently  met  with  in  old  and 
aggravated  cases  in  which  the  mucous  membrane  of  the  urethra  and 
bladder  is  much  congested. 

The  genital  functions  may  be  variously  interfered  with.  In  consequence 
of  the  irritation  of  the  parts,  frequent  erections  may  take  place,  or  noc- 
turnal emissions  occui".  In  other  cases,  erection  is  never  perfect,  owing  to 
the  rigidity  of  the  urethra,  or  an  obstruction  to  the  entrance  of  blood  into 
the  corpora  cavei'nosa ;  pain  may  be  felt  in  sexual  intercourse,  and  the 
semen,  instead  of  being  at  once  ejaculated,  slowly  dribbles  away,  or  passes 
backward  through  the  dilated  urethra  into  the  bladder ;  hence,  persons 
with  stricture  are  frequently  impotent. 

Haemorrhoids,  prolapsus  ani,  and  irritation  about  the  rectum,  which  is 
occasionally  severe,  are  often  produced  by  the  repeated  and  violent  strain- 
ing required  in  emptying  the  bladder.  In  a  similar  manner,  hernia  is 
liable  to  occur,  especially  in  old  men. 

Retention  of  urine  sometimes  supervenes  in  the  early  stages  of  organic 
stricture,  in  consequence  of  congestion  and  spasm  ;  it  may  indeed,  in  rare 
instances,  afford  the  flrst  indication  to  the  patient  that  he  is  the  subject  of 
stricture ;  but  in  most  cases  it  appears  at  a  later  period,  when  the  obstruc- 
tion to  the  passage  of  urine  is  already  very  great.  It  generally  follows 
exposure  to  wet  or  cold,  a  long  ride  or  drive,  and,  most  frequently,  a 
hearty  meal,  at  which  alcoholic  stimulants  have  been  freely  indulged  in. 

Distention  of  the  bladder,  in  such  cases,  may  even  produce  rupture  of 
the  vesical  walls.  If  the  peritonseum  be  involved  in  the  rent,  the  urine 
gains  entrance  to  the  abdominal  cavity  ;  the  vesical  tumor  disappears,  but 
the  abdomen  is  tense  and  swollen,  and  death  soon  occurs  from  peritonitis. 
More  commonly  the  contents  of  the  bladder  are  at  first  effused  into  the 
sub-serous  cellular  tissue,  where  they  may  cause  extensive  gangrene  of 
the  surrounding  parts,  or  whence  they  may  afterwards  escape  into  the  ab- 
dominal cavity  by  ulceration.  In  no  case  of  rupture  of  the  bladder  from 
retention,  has  the  patient  been  known  to  recover.^ 

'  Thompson,  op.  cit. 


CAUSES    OF    STRICTURE.  275 

Still  more  frequently,  the  distention  of  the  bladder  produces  rupture  ot 
the  urethra  behind  the  stricture,  where  its  walls  are  weakened  by  chronic 
inflammation  and  ulceration.  In  the  sudden  and  extensive  infiltration  of 
urine  which  ensues,  no  time  is  given  for  adhesive  inflammation  to  erect 
barriers  to  its  progress,  as  often  happens  in  the  slower  formation  of  urinary 
abscesses,  and  thus  the  urine,  forced  on  by  the  contractile  power  of  the 
bladder,  permeates  the  loose  cellular  tissue,  wherever  it  is  not  limited  by 
the  fasciae.  When  the  rupture  takes  place  anteriorly  to  the  triangular 
ligament,  the  effusion,  after  breaking  through  Buck's  fascia,  extends  for- 
wards and  upwards  into  the  scrotum  and  over  the  abdomen ;  its  extent 
may  generally  be  defined  by  the  swelling  and  discoloration  of  the  integu- 
ment, and  an  emphysematous  crackling  on  pressure,  which  is  due  to  the 
mixture  of  gases  with  the  fluid  ;  the  vascular  connection  between  the 
superficial  and  deeper  tissues  is  cut  oiF  or  impeded,  and,  unless  free  inci- 
sions be  made,  gangrene  of  extensive  portions  of  the  skin  may  ensue. 
Thus,  cases  are  recorded  in  which  the  effusion  perforated  the  superficial 
perineal  fascia  and  extended  down  upon  the  thighs,  and  in  which  the 
greater  part  of  the  integument  from  the  knee  to  the  umbilicus,  including 
the  coverings  of  the  penis  and  scrotum,  sloughed  away,  and  left  the  tes- 
ticles entirely  exposed  and  suspended  only  by  the  spermatic  cords  and  ves- 
sels ;  yet,  even  under  these  circumstances,  recovery  has  been  witnessed. 
A  symptom,  which  is  to  be  regarded  as  of  serious  import,  is  the  appear- 
ance of  a  dark  spot  upon  the  glans  penis,  which  indicates  that  the  in- 
filtration has  gained  access  to  the  corpus  spongiosum  urethras,  and  that 
"ansrene  has  alreadv  commenced. 

"Wlien  rupture  takes  place  posteriorly  to  the  triangular  ligament,  the 
symptoms  may  for  a  time  be  obscure :  as  when  occurring  elsewhere,  the 
patient  often  has  the  sensation  of  something  giving  way,  and  experiences 
temporary  relief  from  his  sufferings  ;  if  the  rent  be  large  enough  to  allow 
of  the  free  escape  of  urine,  the  vesical  tumor  subsides,  and,  tlie  tension  of 
the  parts  being  relieved,  the  patient  may  be  able  to  pass  water,  but  the 
quantity  thus  evacuated  or  drawn  off  is  found  to  be  small;  soon  deep  throb- 
bing pain  is  felt  in  the  periuiXium,  and  symptoms  of  general  depression 
set  in  ;  and  the  urine,  after  burrowing  in  various  directions,  may  approach 
the  surface. 

Causes  of  Stricture. 

A  knowledge  of  the  causes  of  stricture,  and  the  relative  frequency  ot 
their  action,  may  best  be  attained  from  an  analysis  of  a  large  number  of 
cases,  siicli  as  is  furnished  in  the  following  table  prepared  by  Mr.  Thomp- 
son.' It  should  be  observed  that  143  of  these  220  cases  were  collated 
from  the  records  of  University  College  Hospital,  London,  and  49  from 
reports  by  different  surgeons  in  medical  journals  ;  occurring  for  the  most 
part  in  hospital  practice,  they  represent  the  worst  class  of  urethral  con- 
ti'actions. 


216  STRICTURE    OF    THE    URETHRA. 

ANTECEDENTS,  OR  SUPPOSED  CAUSES  OF  220  CASES  OF  STRICTURE.' 

Gonorrheal  Ii[flam)iiafion  in     .  .  .  .  •  •  •  •  •  .164 

Injury  to  Perimcuin          ...........  28 

Cicatrization  of  C/iancres  or  Cliancroids     ........  3 

Ditto,  following  Phaijechena   ..........  1 

Congenital,  including  cases  in  which  the  urethra  may  have  been  small  from 
malformation,  and  those  in  which  marked  irritability  of  the  urinary 
organs  existed  from  childhood,  accompanied  by  an  unusually  small 

stream  ......•••••••  6 

Poisoning  by  Niti-ate  of  Potash,^  Lithotritij,  3Iastnrbation,^  o{  ench  one       .         .  3 
True  Inflammatory  Stricture,  including  temporary  stricture  and  retention  from 
sudden  acute  inflammation,  usually  caused  by  some  excess,  and  disap- 
pearing by  resolution    ..........  8 

T;ue  5jj«S7/wx/ic  kSVrtrtdre,  caused  by  irritation  about  the  rectum    ...  2 

"           "                "         no  cause  assignable         ......  2 

"           "                '•'         caused  by  undue  acidity  or  alkalinity  of  the  urine  3 

220 
Of  the  1G4  cases  attributable  to  gonorrhoea — 

In  90  the  disease  is  reported  to  have  been  chronic  or  neglected. 
"     3  it  was  attributed  by  the  patients  to  strong  injections. 
"     6  the  discharge  is  stated  to  have  ceased  entirely  and  rapidly  under 
treatment ;  but  in  five  of  these  stricture  appeared  almost  immedi- 
ately after. 
"     4  other  cases  the  stricture  appeared  to  be  almost  simultaneous  with 
the  gonorrhcea. 
In  the  remaining  61  there  is  no  report  of  chronicity,  etc. 

Of  the  164  cases  attributable  to  gonorrhoea — 

10  appeared  immediately  after,  or  during  the  attack  ; 

71         "         within  1  year  of  its  occurrence  ; 

41         "  "      3  or  4  years ; 

22         "  "      7  or  8  years ; 

20  are  reported  at  periods  between  8  and  20  to  25  years. 

It  appears  from  the  above  table  that  gonorrlicea  holds  the  first,  and  in- 
juries of  the  perina?um  the  second  rank  in  tlie  etiology  of  stricture. 

Urethral  contractions  are  favored  by  the  long  continuance,  rather  than 
the  severity,  of  urethritis.  If  we  omit  the  Gl  cases  of  the  above  table  in 
which  there  is  no  report  of  the  duration  of  the  preceding  gonorrhoea,  we 
find  that,  in  nearly  nine-tenths  of  the  remainder,  the  urethral  inflamma- 
tion, to  which  the  stricture  was  attributable,  was  either  chronic,  or 
ne<'-lected.  Inquiries  addressed  to  patients  laboring  under  stricture  show 
that,  in  the  great  majority,  the  urethral  contraction  has  been  preceded  by 
several  attacks  of  gonorrhoea ;  but,  whether  by  one  or  more,  that  the  last 
was  prolonged  for  many  weeks  or  months,  and  terminated  in  a  gleet.  We 
may  hence  infer  that  whatever,  either  in  tiie  patient's  mode  of  life  or  in 
liis  constitutional  tendencies,  prolongs  the  duration  of  a  gonorrhoea,  tends 
to  produce  stricture. 

1  Thompson,  op.  cit.  p.  124.  2  Medi(-al  Times,  Lond.,  June  22,  1844. 

3  Lallemaxi),  Cliniijue  Medico-Chirurgicale,  Ire  part,  p.  109. 


DIAGNOSIS.  277 

Laceration  ot  the  urethral  walls  during  chordee,  and  wounds  from  the 
imprudent  use  of  sounds,  catheters,  etc.,  require  a  passing  notice.  The 
former  may  occur  spontaneously,  or  arise  from  the  hahit,  more  prevalent 
among  Frenchmen  than  Americans,  of  relieving  chordee  by  forcibly  ex- 
tending the  penis ;  or,  as  is  said,  "  breaking  the  chord."  Wounds  of 
the  urethra  by  instruments  from  within  evidently  have  the  same  effect  as 
from  without ;  in  the  process  of  cicatrization  which  ensues,  the  natural 
coaptation  of  the  parts  must  frequently  be  lost,  and  fibro-plastic  material 
endowed  with  contractile  properties  be  deposited.  A  distinction,  however, 
is  to  be  made  between  transverse  and  longitudinal  wounds  of  the  urethra 
from  witliin.  The  former  only  may  be  said  to  be  likely  to  produce  stric- 
tures. Such  results  do  not  follow  longitudinal  incision,  made,  for  instance, 
in  internal  urethrotomy. 

Much  influence  in  the  production  of  stricture  has  been  attributed  to  tlie 
use  of  injections.  I  feel  obliged  to  dissent  in  toto  from  this  opinion,  whicli 
appears  to  me  to  be  based  upon  reasoning  post  hoc  ergo  propter  hoc. 
When  made  very  strong,  or  used  at  an  improper  stage  of  the  disease,  or 
with  excessive  force,  injections  may  doubtless  act  as  escharotics,  or  aggra- 
vate the  inflammatory  action,  and  thus  favor  urethral  contraction,  but  this 
effect  pertains  only  to  their  abuse. 

A  chancre  or  chancroid,  like  any  other  ulcer,  destroys  a  certain  portion 
of  the  tissues  upon  which  it  is  situated,  and  this  loss  of  substance  is  not 
restored  in  the  process  of  cicatrization,  but  the  gap  is  filled  with  fibro- 
plastic deposit,  in  the  form  of  granulations,  which  gradually  contracts  and 
approximates  the  edges  of  the  original  sore,  or  which  forms  a  hard  un- 
yielding cicatrix  between  them.  In  this  manner  venereal  ulcers  situated 
upon  any  portion  of  the  urethral  mucous  membrane  may  lay  the  founda- 
tion of  stricture.  Examples  of  this  kind  are  most  frequently  seen  in  sores 
upon  the  margin  of  the  meatus,  or  in  the  fossa  navicularis. 

Diagnosis. 

The  general  symptoms  alone  might  be  considered  suflficient  to  indicate 
a  case  of  stricture,  but  in  many  instances  are  very  deceitful.  There  are 
other  affections  of  the  urinary  organs,  the  symptoms  of  which  closely  re- 
semble those  of  stricture,  and  which  have  often  been  mistaken  for  it. 
Experience,  therefore,  would  show  that  the  greatest  care  should  always  be 
employed  in  forming  a  diagnosis.  Tiie  diseases  which  are  most  likely  to 
be  confounded  with  organic  stricture,  are  subacute  iuHaiiiniation  of  the 
prostate,  and  urethral  neuralgia  and  hyperaisthesia, 

S,ubacute  inflammation  of  the  ])rostate  may  be  attended  by  nearly  every 
symptom  which  has  been  described  as  belonging  to  stricture,  viz.,  by  fre- 
(juency  and  difficulty  of  micturition,  gleety  discharge,  and  pain  in  the 
perinaium,  above  the  pubes,  and  elsewhere.  This  identity  in  the  symp- 
toms may  readily  lead  to  a  mistake  in  diagnosis,  which  may  even  be  con- 
firmed by  a  superficial  exploration  of  the  un-thra  ;  for  the  prostatic  portion 
of  the  canal,  in  this  affection,  is  exceedingly  sensitive  and  the  introduction 


278  STRICTURE    OF    THE    URETHRA. 

of  a  catheter  attended  with  sevei-e  pain  ;  if,  then,  the  surgeon  yields  to  the 
feelings  of  the  patient  and  fails  to  malie  a  thorough  examination,  or,  if  he 
employs  a  tine  sound  or  bougie,  the  point  of  which  is  liable  to  be  obstructed 
by  catching  in  some  lacuna  of  the  mucous  membrane,  the  erroneous  con- 
clusions already  drawn  from  the  history  of  the  case  may  apparently  be 
confirmed. 

The  same  mistake  may  also  occur  in  cases  of  urethral  hypersesthesia, 
either  when  occasioned  by  sympathetic  irritation  from  stone  in  the  blad- 
der, affections  of  the  rectum,  etc.,  or  when,  in  the  absence  of  any  apparent 
cause,  tlie  exalted  sensibility  can  be  attributed  only  to  nervous  derange- 
ment. Tlie  diagnosis  of  a  suspected  case  of  stricture  can,  therefore,  be 
founded  only  upon  a  careful  and  thorough  exploration  of  the  urethra,  and 
the  instruments  required  in  such  examination,  and  tlie  manner  of  using 
them,  will  now  claim  our  attention. 

Exploration  of  the  Urethra — The  instruments  requisite  for  phy- 
sical exploration  of  the  urethra,  and  the  diagnosis  of  stricture,  most  of 
which  are  also  useful  in  treatment,  are  a  set  of  sounds,  solid  and  flexible 
catheters,  and  bougies  of  various  forms.  I  propose  to  describe  those  only 
which  I  have  I'ound  most  useful  in  practice. 

Shape  and  Size  of  Metallic  Instruments. — Tlie  degi-ee  of  curvature  of 
unyielding  instruments  used  in  urethral  exploration  is  a  matter  of  no  small 
importance.  It  would  seem  desirable  that  the  curve  should  correspond  to 
the  natural  curvature  of  the  least  movable  portion  of  the  urethra  itself, 
which  is  that  portion  underlying  the  symphysis  [mbis.  Mr.  Thompson  has 
adopted  this  principle  in  the  construction  of  catheters  and  sounds,  and  his 
example  has  of  late  been  very  generally  followed,  since  it  has  been  found 
that  experience  confirms  the  deductions  from  theory,  and  that  urethral 
instruments  with  such  a  curvature  are  most  readily  introduced.  The  sub- 
pubic curve  is  an  arc  of  a  circle  three  and  a  (juarter  inches  in  diameter, 
or,  in  other  words,  of  a  circle  described  by  a  radius  one  and  five-eighths 
of  an  inch  in  length,  the  chord  of  the  arc  measuring  two  inches  and  three- 
quarters.  The  accompanying  figure  exhibits  a  catheter  and  sound  so  bent 
as  to  corresj)ond  to  this  curve. 

In  order  that  the  precise  direction  of  the  point  of  the  instrument  may 
be  indicated  by  the  direction  of  its  shaft,  it  is  desirable  that  a  constant 
relationship  should  exist  between  the  two.  According  to  the  principle  of 
construction  here  recommended,  this  is  a  right  angle  in  the  catheter,  and 
in  the  sound,  a  somewhat  shorter  instrument,  an  angle  of  120^^,  or  a  right 
angle  and  a  third. 

Another  form  of  sound,  known  as  Benique's,  is  a  very  desirable  one  in 
some  cases.  It  has  a  double  curve  corresponding  nearly  to  the  two  curves 
of  the  urethra  when  the  penis  is  not  elevated  against  the  pubes,  and  hence 
is  of  the  sam(^  shape  that  a  flexible  bougie  assumes  when  introduced  into 
the  bladder  and  abandoned  to  itself.  When  properly  made,  it  will  be 
found  on  examination,  as  shown  in  the  diagram,  that  its  extremity  follows 


EXPLORATION    OF    THE    URETHRA. 


279 


the  same  curve  as  that  above  described,  but  that  it  includes,  a  larger  arc  ot 
the  circle.     Its  point  is  likewise  at  aright  angle  with  its  shaft. 

As  to  the  choice  between  these  two  forms  of  sound,  it  may  be  said :  in 
practised  hands  they  are  generally  equally  easy  of  introduction,  although 


Fis:.  59. 


A  B  represents  an  arc  of  a  circle  three  and  a  quarter  inches  in  diameter  (radius  \%  in.)  ;  a  B  b, 
a  catheter  with  Thompson's  curve  ;  f  B  e,  a  sound,  with  the  same  curve,  but  shorter;  c  b  d,  a 
large  Bunique's  sound,  its  extremity  following  the  same  curve,  hut  including  a  larger  arc  of  the 
circle. 

I  have  met  with  cases  in  which  the  one  entered  more  readily  tlian  the 
other.  For  many  years,  I  have  been  in  the  habit  of  using  the  short  sound 
with  Thompson's  curve  for  the  dilatation  of  stricture, — when,  of  course, 
there  would  be  no  object  in  reaching  the  deepest  portion  of  the  canal, — 
and  of  using  a  long  sound  with  IJeniqiie's  curve  in  the  treatment  of  cases 
of  irritability  of  the  neck  of  the  bladder  or  whenever  it  is  desirable  to  have 
the  instrument  enter  this  viscus  and  be  retained  for  a  time. 

The  greatest  confusion  formerly  prevailed,  and  still  prevails  to  a  con- 
siderable extent,  concerning  the  numbering  of  catheters  and  sounds.  We 
hear  of  an  "  PiUglish  scale,"  but  there  is  no  such  thing  as  a  constant  Eng- 
lish scale,  since  the  numbers  of  no  two  English  makers  exactly  correspond, 
although  they  do  approximately,  and  we  cannot  as  yet  dispense  witli  the 
term,  however  inaccin-ate.  The  French,  on  the  contrary,  have  a  definite 
standard,  and  if  you  Ijuy  half  a  dozen  fih'eres  of  as  many  different  instru- 
ment  makers  in   France,  you   will  find  them   all  to  agree.     Besides  this 


280 


STRICTUttE    OF    THE    URETHRA. 


recommendation  of  uniformity,  the  French  scale  has  also  this  advantage, 
that  the  steps  of  its  gradation  are  shorter  than  the  English,  which  is  often 
very  desirable  in  dilating  strictures. 

The  French  scale,  often  known  as  the  Charriere-jiirere,  progresses  by 
steps  of  one-third  of  a  millimetre  in  diameter,  that  is  to  say:  No.l  repre- 
sents an  instrument  one-third  of  a  millimetre  in  diameter,  No.  2  two-thirds, 
No.  3  three-thirds  or  one  millimetre.  Given  the  number  of  the  instru- 
ment, and  you  know  its  diameter  in  as  many  thirds  of  a  millimetre. 

I  have  italicized  the  word  diameter,  because  in  the  previous  edition  of 
this  book  I  made  the  stupid  mistake  of  saying  that  the  number  of  each 
instrument  represented  its  circumference  in  millimetres,  and  other  writers 
have  followed  my  bad  example.  If  the  circumference  of  a  circle  were 
exactly  three  times  its  diameter,  my  statement  would  have  been  true, 
but,  of  course,  it  is  not.  The  diameter  is  to  the  circumference  as  1  is  to 
3.14159,  and  although  this  fraction  beyond  the  three  might  be  ignored  in 
estimating  the  circumference  of  the  smaller  numbers  of  sounds,  yet  its 
multiplication  in  the  higher  numbers  makes  no  little  difference.  The 
following  table  exhibits  the  diameters  and  the  circumferences  of  sounds 
from  numbers  one  to  forty  inclusive  according  to  the  French  scale: — 


c  o 

d  « 

C   (p 

-  1 

No. 

j  5 

*  s 

<£■- 

No. 

11 

e3 

No. 

sS 

No. 

'Z  2 

e£ 

t  S 

Sz: 

ga 

E  Z^ 

ga 

E  z: 

ga 

5"^^ 

*•- 

o"" 

1 

0.33 

1.0.5 

11 

3.67 

11.52 

21 

7.00 

21.99  1 

31 

10.33 

32.46 

2 

0.67 

2.09 

12 

4.00 

12.57 

22 

7.33 

23.04 

32 

10.67 

33.51 

3 

1.00 

3.14 

13 

4.33 

13.61 

23 

7.67 

24.08 

33 

11.00 

34.56 

4 

1.33 

4.19 

14 

4.67 

14.66 

2A 

8.00 

25.13 

34 

11.33 

35.60 

5 

1.67 

5.24 

15 

5.00 

15.71 

25 

8.33 

26.18 

35 

11.67 

36.65 

6 

2.00 

6.28 

16 

5.33 

16.76 

26 

8  67 

27.23 

36 

12.00 

37.70 

7 

2.33 

7.33 

17 

5.67 

17.80 

27 

9.00 

28.27 

37 

12.33 

38.75 

8 

2.67 

8.38 

18 

6.00 

18.85 

28 

9.33 

29.32 

38 

12.67 

39.79 

9 

3.00 

9.42 

19 

6.33 

19.90 

29 

9.67 

30.37 

39 

13.00 

40.84 

10 

3.33 

10.47 

20 

6.67 

20.94 

30 

10.00 

31.42 

40 

13.33 

41.89 

It  will  thus  be  seen  that  when  Dr.  X,  who  bases  his  "  French"  scale  on 
circumferences,  tells  us  that  he  has  divided  a  stricture  up  to  30,  he  has 
really  divided  it  to  less  than  20  of  the  true  French  scale,  and  that  when 
he  says  40,  he  should  say  a  little  over  38,  etc.  etc. 

Drs.  Van  Buren  and  Keyes  have  proposed  a  scale,  which  they  liave 
christened  "  The  American  (  ?)  scale,"  and  which  is  intrinsically  better 
than  the  French  scale,  since  it  progresses  by  half  millimetres  in  diameter 
and  thus  avoids  the  thirds  of  millimetres  of  tlie  French  scale,  evidently  an 
undesirable  departure  from  the  metric  system.  I  must,  however,  object 
to  the  introduction  of  any  new  scale,  when  one  already  exists  that  is  known 
and  used  iis  a  standard  by  so  many  surgeons  in  every  civilized  country. 
To  depart  from  tliis  standard  on  one's  own  responsibility  is  merely  to  in- 


EXPLORATION    OF    THE    URETHRA. 


281 


troduce  inextricable  confusion.     Fig.  60  represents  the  Charriere-filiere, 
with  the  numbers  (expressing  thirds  of  millimetres  in  diameter)  above  the 


Fig.  60. 


20  21  22  23  24  25  26  27  28 


15  15  16 


16         15        14       13 


D  O  O  OOQ  OO    O    Q   O   o    o 


11  10  10  9  9 


G  .TIEM4NN-  CO. 


7      6      s^^aaai 


openings.  For  the  sake  of  comparison,  I  have  added  below  the  openings 
the  corresponding  numbers  of  the  English  scale  with  as  great  accuracy  as 
I  have  been  able  to  estimate  them. 


Fig.  61. 


FiK.  62. 


£ 

n 

-^ 

■  "    tjs|     I 

r  2 

H                     1  1  {:{:  ^H'll^  1                      1 

nil 

III! 

-=3:3 

mmunui^Rn   JE 

am\uau 

C.TI£MAWM.».CC.^ 


It  should  be  observed,  that  in  the  present  work 
Avhenever  the  size  of  urethral  instruments  is  men- 
tioned, the  number  of  the  French  scale  is  intended. 

.For  measuring  the  diameter  of  a  given  instrument, 
supposing  the  same  to  be  unknown,  we  may  employ 
the  gauge  represented  in  Fig.  Gl. 

A  still  more  convenient  gauge,  however,  has  been 
invented  by  Dr.  H.  Ji.  Ilanderson,  of  New  York,  and 
is  shown  in  Fig.  02.    The  catlieter,  sound,  etc.,  to  be 


1 

1 

2 

2 

3 

T 

1                * 

4 

\               5 

^ 

5 

7 

8 

6 

9~ 

7 

10 

II 

1         '^ 

> 

q 

13 

n 

10 

14- 

15 

H 

16 

17 

n 

12 

\& 

> 

13 

19 

z 

20 

i  '■* 

21 

M  1  15 

1         ^ 

o  ■ — 

23 

> 

16 

24 

17 

25 

26 

\a 

27 

19 

28 

20 

— 2_9_J 
30 

21 

31 
32 

2Z 

33 

7^ 

34. 

35 

24 

36 

?S 

37 

38 

26 

39 

40 

282 


STRICTURE    OF    THE    URETHRA. 


measured,  is  simply  to  be  inserted  in  the  base  of  the  opening  and  slid 
towards  the  apex  as  far  as  it  will  go,  when  the  parallel  lines  on  either  side 
will  indicate  its  size  according  to  both  the  French  and  the  Van  Buren- 
Keyes  scale. 

Catheters  are  conveniently  made  somewhat  longer  than  the  canal  they 
are  designed  to  traverse,  and  usually  measure  about  eleven  inches.  The 
handle  of  the  catheter  is  provided  with  a  firm  oval  ring  attached  to  each 
side,  in  order  that  the  least  twisting  of  the  instrument  on  its  axis  during 
its  introduction  may  be  at  once  manifest  to  the  operator,  and  also  to  permit 
of  its  being  retained  as  a  permanent  catheter.  The  vesical  extremity  of 
the  instrument  has  two  eyes  for  the  entrance  of  urine,  one  situated  half  an 

FiK.  63. 


Compound  male  aud  female  catheter. 

inch,  and  the  opposite  one  an  inch  from  the  extremity.  They  are  often 
made  too  large,  and  allow  of  tlie  protrusion  of  folds  of  the  lining  membrane 
of  the  canal,  obstructing  the  passage  of  the  catheter,  and  exciting  unneces- 
sary pain.  Their  edges  should  be  bevelled  off  with  nicety.  Instead  of 
these  two  lateral  eyes,  the  end  of  the  catheter  is  sometimes  piei'ced  with 

Fi-'.  64. 


'liemann's  V(4vet-eye  catheter. 


numerous  small  apertures,  which  are  objectionable  on  account  of  their 
liability  to  become  clogged  with  blood  or  mucus. 


Fijr.  65. 


Otis's  prostatic  guide. 


A  "  complete  set"  of  catheters  is  entirely  unnecessary.     As  they  are 
used  only  for  evacuating  the  bladder,  a  large  and  a  small  one  (Nos.  8  and 


CATHETERS. 

Fio-.  66. 


283 


284 


STRICTURE    OF    THE    URETHRA. 


20  French),  besides  a  probe-pointetl,  a  prostatic,  and  a  female  catheter, 
fulfil  every  purpose.  The  "  compound  male  and  female  catheter"  (Fig.  63) 
is,  however,  a  requisite  for  every  pocket-case  of  instruments. 

Of  gum-elastic  catheters,  those  made  by  the  French,  with  a  conical  end 
and  a  bulbous  point  (see  Fig.  68)  are  often  of  value,  on  account  of  the  ease 
and  safety  of  their  introduction.  They  are  admirably  fitted  for  a  patient's 
own  use,  since  their  flexibility  i*enders  it  almost  impossible  for  him  to  do 
himself  harm.  In  cases  of  enlarged  prostate,  however,  there  is  nothing 
equal  to  the  Nelaton  catheter,  of  pure  rubber,  which  is  now  made  in  Eng- 
land of  superior  stability  and  outside  finish  and  which  is  commonly  known 
as  Jaque's  catheter.  It  is  also  made  in  this  country  by  Geo.  Tiemann 
&  Co.,  who  claim  to  have  improved  the  eye  of  the  instrument  so  that  it 
cannot  excite  irritation  in  its  passage  (Fig.  64). 

In  some  instances  it  is  desirable  to  impart  to  this  instrument  increased 
firmness  witliout  impairing  its  elasticity,  in  which  case  the  stylet  or  guide 
of  Prof.  Otis,  consisting  of  a  light  steel  rod  (a)  eight  inches  in  length, 
upon  which  is  screwed  a  spiral  riband  (b)  five  inches  in  length,  will  be 
found  of  value  (Fig.  65). 

A  silver  prostatic  catheter,  with  more  than  the  usual  curve  and  a  long 
beak,  should  always  be  at  hand.  Fig.  66  represents  the  size  and  shape  ot 
one  which  has  never  yet  failed  me  in  cases  of  retention  of  urine  from 
enlargement  of  the  prostate. 

Squire's  vertebral  catheter  (Fig.  67)  is  also  highly  esteemed  by  many 
of  our  best  authorities  in  cases  of  prostatic  obstruction,  but  many  accidents 


Squire's  vertebral  catheter. 


have  occurred  from  the  separation  and  detachment  of  its  links,  owing  to 
imperfect  construction,  and  it  may  well  be  supplanted  by  the  Jaque's 
catheter,  with  or  without  a  stylet,  already  mentioned. 

Sounds Tlie  best  sounds  are  made  of  "  Stubb's  steel,"  and  are  either 

highly  "  polished  in  oil,"  or,  more  frequently  at  the  present  day,  nickel- 
plated,  both  to  avoid  rust  and  to  present  a  smooth  surface  to  the  urethral 
walls.  For  reasons  already  given,  I  prefer  to  have  in  my  office  two  full 
sets,  one  of  Tliompson's,  the  other  of  Benique's,  curve.  The  former,  how- 
ever, may  be  made  to  answer  every  purpose,  and  are  (juite  sufficient  for  a 
case  of  instruments  to  take  to  an  operation  or  for  the  use  of  a  general  prac- 
titioner. They  should  range  in  size  from  number  12  to  36,  or  even  40.  In 
cases  of  stricture  so  tight  as  not  to  admit  No.  12,  it  is  better  to  employ  bou- 
gies, since  the  stiffness  of  a  small  metallic  instrument  exposes  to  the  danger 


BOUGIES. 


285 


Fiff.  68. 


0 


n 


of  making  a  false  passage.  Their  handles  should  be  broad  and  roughened, 
so  as  to  afford  a  secure  hold  to  the  hand  and  indicate  any  deviation  in  the 
direction  of  the  point.  It  is  well  to  have  the  points  gradually  tapering  to 
two  sizes  smaller  than  the  shaft,  and  the  same  arrangement  enables  us  in 
making  up  an  out-door  case  of  urethral  instruments  to  economize  space  by 
dispensing  with  every  other  number  of  the  scale. 

Bougies. — Bougies  are  made  of  wax,  gum  elastic,  whalebone,  and  other 
materials,  and  are  furnished  with  variously  shaped  points. 

The  English  mahogany-colored  bougies,  which  on  account  of  their  dura- 
bility are  so  commonly  found  in  surgical  cases  in  hospitals  and  private 
offices,  are  objectionable,  except  in  certain  cases  of  prostatic 
obstruction  in  which  considerable  stiffness  of  the  instrument 
is  called  for,  because  of  their  not  readily  following  the 
natural  curve  of  the  urethra.  They  are  the  source  of  much 
of  the  pain  and  even  injury  so  often  inflicted  upon  patients 
in  catheterization.  No  other  bougies  can  equal  those  made 
by  the  French,  which  are  black  in  color,  highly  flexible, 
conical  towards  the  extremity,  and  furnished  with  an  olive- 
shaped  point,  which  prevents  their  catching  in  the  lacunje 
of  the  canal. 

"  Filiform  bougies"  of  the  same  material  are  indispensable 
in  the  treatment  of  tight  strictures,  and  should  be  in  the 
hands  of  every  surgeon  who  attempts  to  treat  such  cases. 
If  their  value  were  better  known,  we  should  hear  of  fewer 
instances  of  "impassable"  strictures. 

Fine  whalebone  bougies  (Fig.  (39),  some  with  straight 
and  others  with  eccentric  and  twisted  points,  are  also  of 
value  in  cases  of  tight  strictures  in  the  anterior  portion  of 
the  uretlira,  but  on  account  of  their  stiflfness  they  are  less 
adapted  to  strictures  in  tlie  sub-pubic  curvature. 

The  desired  shape  and  stiffness  may  be  imj)arted  to  the 
points  of  fine  flexible  bougies  by  first  soaking  them  in  hot 
water,  then  twisting  tliem  as  required,  and  finally  plunging  them  into  cold 
water.     Or,  again,  tlie  twisted  points  may  be  covered  with  several  coats 
of  collodion,  which  will  retain  tlieir  form  even  wlien 
exposed  to  the  secretions  of  the  urethra  and  the  urine. 

The  employment  of  gum-elastic  and  whalebone  fili- 
form bougies  as  guides  in  internal  urethrotomy  and 
in  the  rupture  of  strictures,  will  be  mentioned  here- 
after. 

All  bougies  should  be  carefully  examined  from  time 
to  time,  and  if  found  impaired  in  the  slightest  degree 
should  at  once  be  destroyed,  lest  they  be  incautiously 
used  and  a  portion  break  oft' in  the  canal.  Bougies  of 
elastic  gum  become  rough  with  use,  whereby  they  irritate  the  mucous  mem- 
brane, and  should  in  this  case  also  be  discarded.  After  using  them,  they 
should  be  wiped  quite  dry  and  free  from  oil,  which  acts  on  the  rubber,  and 


Frencli  flexi- 
ble bougie  and 
catheter. 


Fisr.  69. 


nF.Fono 


^\ 


■^v. 


Fine  whalobonobougies 
twisted  points. 


286  STRICTURE    OF    THE    URETHRA. 

then  be  dusted  ovei*  with  powdered  soapstone,  and  be  kept,  in  warm  weather, 
in  a  cool  place,  as  in  an  ice-chest.  But  no  rubber  material  can  be  long 
kept  in  our  climate,  hence  it  is  desirable  for  the  surgeon  to  replenish  his 
drawers  sparingly  at  any  one  time.  Whalebone  bougies  must  be  oiled 
occasionally,  or  they  become  brittle  and  unsafe. 

The  question  has  arisen,  which  is  the  less  painful  to  the  patient,  the 
introduction  of  a  metallic  or  flexible  instrument  ?  My  own  preference, 
except  in  somewhat  tight  strictures,  is  decidedly  in  favor  of  the  former, 
and  this  preference  is  founded  on  the  statements  of  my  patients  when  I 
have  had  occasion  to  use  both.  I  would  certainly,  liowever,  recommend 
one  who  was  not  in  the  habit  of  using  instruments,  to  employ  the  latter 
(flexible),  but  as  my  friend  Dr.  Ashhurst*  justly  remarks,  "  the  practi- 
tioner will  do  wisely  not  blindly  to  follow  one  exclusive  method,  but  to 
vary  his  remedies  according  to  the  exigencies  of  each  particular  case." 

Acorn-  (^-^  bulbous")  pointed  Sou7ids  and  Bovgies — We  are  indebted 
for  the  original  conception  of  these  instruments  to  Chas.  Bell,'^  who,  as 
early  as  1807,  described  them  under  the  name  of  "ball-probes,"  and 
claimed  for  them  all  the  advantages  which  they  have  since  been  proved 
to  possess.  Bell's  instruments,  as  the  name  he  gave  them  indicates,  were 
ball-shaped  or  spherical  at  their  extremity  ;  they  were  made  of  metal,  both 
ball  and  shaft.  The  ball-shaped  head  was  afterwards  changed  to  one  of  an 
olive  form.  This  was  no  improvement,  since  a  sphere  will  better  detect  a 
sliglit  contraction  than  any  bulb  of  an  olive-shape.  An  actual  gain  was 
acquired  in  making  the  terminal  bulb  like  an  acorn  with  a  somewhat 
abrupt  shoulder,  thereby  facilitating  the  introduction  of  the  instrument 
and  at  the  same  time  increasing  its  accuracy  of  diagnosis  upon  withdrawal. 
Leroy  d'EtioUes'*  recommended  the  same  instruments  made  of  flexible 
material.  As  now  chiefly  used,  made  of  metal  and  with  acorn-shaped 
bulbs,  they  were  described  in  the  first  edition  of  this  work  (p.  275),  pub- 

Fi-.  70. 


Acoru-poiutPd  sounds. 

lished  in  18G1,  when  they  had  long  been  in  common  use.  It  is  desirable 
to  have  them  in  sets,  like  sounds  ranging  in  size  from  12  upwards, 
nickel-plated,  their  shafts  straight  and  about  six  and  a  half  inches  long, 

'  The  Principles  and  Practice  of  Surgery,  2d  ed.,  1878,  p.  913. 

"  Chas.  Bell,  Operative  Surgery,  Am.  reprint,  Phil.,  1812,  vol.  i,  p.  72. 

3  Traite  d.  angusties  d.  Turetre,  Paris,  1845,  p.  122. 


BOUGIES.  281 

with  a  disk  upon  the  distal  end  upon  which  the  number  is   marked  (Fio-. 
68). 

This  form  is  the  most  generally  useful,  but  it  should  be  distinctly  under- 
stood that  it  is  adapted  only  for  exploration  of  that  portion  of  tlie  urethra 
anterior  to  the  triangular  ligament.  If  it  be  desired  to  explore  beyond 
this  point,  we  must  either  use  a  similar  instrument  which  I  have  had 
constructed  curved  like  an  ordinary  sound  (Fig.  71),  or  employ  the  acorn- 
Fig   71. 


Curved  acorn-pointed  sound. 


pointed  bougie,  made  of  flexible  material  (Fig.  72).  In  practice,  how- 
ever, bulbous  sounds  or  bougies  are  rarely  resorted  to  for  exploration  of 
the  deeper  portion  of  the  canal. 

Fig.  72. 


OS 


Acorn-pointed  bougies. 

The  advantages  offered  by  these  instruments  are  the  following:  They 
enable  us  to  detect  and  locate  points  of  tenderness  in  the  canal,  where  a 
chronic  gonorrhoea  or  gleet  very  likely  has  its  seat.  They  are  a  valuable 
means  for  determining  the  presence  of  slight  contractions  or  the  so-called 
"  strictures  of  large  calibre."  It  is  commonly  said  that  they  enable  us  to 
determine  the  length  of  strictures,  but  this  is  evidently  impossible,  unless 
the  stricture  terminate  abruptly  at  each  extremity,  wliich  is  rarely  the 
case.  A  stricture  is  usually  shaped  like  an  hour-glass,  and  more  or  less 
contraction  exists  before  the  obstruction  is  encountered  by  any  sound  that 
can  be  made  to  pass  through  it.  The  presence  of  a  slight  stricture  is 
better  detected  on  the  withdrawal  than  on  the  insertion  of  tlie  sound,  since 
the  abrupt  base  of  the  bulb  then  impinges  more  decidedly  against  it.  If 
a  second  stricture  exist  beyond  the  first  and  tighter  than  the  latter,  it  may 
be  detected  by  the  acorn-pointed  sound. 

The  size  of  the  meatus  is  conveniently  measured  by  meatometers,  such 
as  recently  figured  and  described  by  Prof.  Henry  G.  Pifiiird.^  The  accom- 
panying cut  (Fig.  73)  will  explain  itself.  It  is  desirable  to  have  two  on 
liand,  so  as  to  include  the  whole  scale  of  sizes  to  which  the  meatus  is  liable, 
each  being  marked  with  the  numbers  corresponding  to  its  divisions.  If  tiie 
surgeon  wishes  to  multiply  liis  instruments  in  this  direction,  lie  may  do  so 
with  short  bougies  a  boule  (Fig.  74).  This  refinement,  however,  is  hardly 
necessary  to  those  not  over-blest  pecuniarily. 

'   Physician  and  Phannac,  N.  Y.,  Jan.  1,  1879. 


288 


STRICTURE    OF    THE    URETHRA. 

Fig.  73. 


Fig.  75. 


Otls's  urethrometer 


Piffiird's  "  fossal  bouaries  a  boule." 


Urethrometer. — Since  the  meatus  is  usually  the  small- 
est part  of  the  urethra  and  varies  very  much  in  its  calibre, 
it  may  not  allow  the  introduction  of  any  of  the  instruments 
thus  far  mentioned  of  sufficient  size  to  thoroughly  explore 
the  canal  and  especially  to  detect  slight  contractions.  An 
instrument  which  could  be  inserted  through  a  narrow  me- 
atus and  then  be  dilated  within  the  urethra,  with  an  index 
at  its  distal  extremity  showing  the  amount  of  its  dilatation, 
was  therefore  a  desideratum.  This  want  has  been  supplied 
by  the  ingeniously  contrived  urethrometer  of  Prof.  Otis 
(Fig.  75),  who  describes  it  as  follows  : — ^ 

"  It  consists  of  a  small,  straight  canula,  size  No.  8, 
French,  terminating  in^  a  series  of  short  metallic  arms, 
hinged  upon  the  canula  and  upon  each  other.  At  the  dis- 
tal extremity  where  they  unite,  a  fine  rod,  running  through 
the  canula,  is  inserted.  This  rod  (which  is  worked  by  a 
stationary  screw  at  the  handle  of  the  instrument),  when 
retracted,  expands  the  arms  into  a  bulb-like  shape,  10 
millimetres  in  circumference  when  closed,  and  capable  of 
expansion  up  to  40  millimetres.  A  thin  rubber  stall 
(C)  drawn  over  the  end  of  the  closed  instrument,  pro- 
tects the  urethra  from  injury  and  prevents  the  access 
of  the  urethral  secretions  to  the  interior  of  the  instru- 
ment. When  introduced  into  the  urethra  and  expanded 
up  to  a  point  which  is  recognized  by  the  patient  as  filling 
it  completely — and  yet  easily  moving  back  and  forth — the 
index  at  the  handle  then  shows  the  normal  circumference 
of  the  urethra  under  examination.  In  withdrawing  the 
instrument,  contractions  at  any  point  may  be  exactly 
measured,  and  any  want  of  correspondence  between  the 
calibre  of  the  canal  and  the  external  orifice  be  readily 
aj)preciated.  Among  the  advantages  claimed  for  this 
instrument  are :  I.  Its  capacity  to  measure  the  size  of 
the  urethra  and  to  ascertain  the  locality  and  size  of  any 


'  Stricture  of  the  Male  Urethra,  N.  Y.,  1868,  p.  77. 


URETHROMETER. 


289 


strictures  present,   without  reference  to   the  size  Fig.  76. 

of  the  meatus.  II.  It  enables  the  sui^eon  to 
complete  the  examination  of  several  strictures 
by  a  single  introduction  of  the  instrument." 

While  admitting  the  great  advance  made  by 
Dr.  Otis  in  enabling  us  to  determine  more  accu- 
rately the  size  of  the  urethra  at  its  various  points, 
yet  his  instrument  possesses  this  defect :  its  ex- 
tremity is  of  an  elongated  olive  shape,  and  hence 
is  less  capable  of  indicating  a  slight  contraction 
than  if  it  were  of  an  acorn  form — the  same  ob- 
jection that  is  made  to  Bell's  original  ball- 
probes,  only  still  greater.  This  defect  is  reme- 
died in  B.  AVills  Richardson's  urethrometer,^ 
and  also  in  one  invented  by  Prof.  Robt.  F.  Weir, 
of  New  York  (Fig.  76). 

Dr.  Otis  believes  that  a  constant  relative  pro- 
portion exists  between  the  calibre  of  the  urethra 
and  the  size  of  the  penis,  as  follows  :  When  the 
flaccid  penis,  about  three-fourths  of  an  inch  back 
of  the  corona  glandis,  measures  3  inches  in  cir- 
cumference, the  size  of  the  urethra  is  30  milli- 
metres in  circumference,  or  more.*  When  it  is 
3^^  inches,  it  is  32  or  more  ;  3^  inches,  34  ;  3| 
inches,  oG  ;  4  inches,  38  ;  4^  to  A^  inches,  40  or 
more  millimetres.  The  constancy  of  this  rela- 
tionship is  denied  by  Dr.  R.  F.  Weir,^  but  seems 
to  have  been  received  generally asat  least  approxi- 
matively  correct,  and  hence  of  considerable  prac- 
tical value. 

The  urethrometer  is  commonly  introduced  as 
far  as  the  bulbous  portion  of  the  inx'thra,  that  is 
to  say,  about  4^  to  o  inches,  before  being  dilated. 
Upon   witlidravving    it,  it  will    usually   be  found 

'  ,  •/  1  .>  o         Ml-        .-  Dr.  Weir's    nrethroiiictor.— 

necessary  to  screw   it  down  2  or  3  millimetres     The  rings  uu  the  shaft  i-.c^te 
when  it  arrives  at  3^  or  3  inches  from  the  meatus     "'^  points  of  arrest,  ami  per- 

,.     ,,      ,        ,.,  .,  ,ri,  1.      .  niit  subsoqueiit  accurate  iiiea- 

even  in  penectly  healthy  uretiira?.      lluisdimin-     suremeut. 
ished  in  size,   it  ought,  according  to  the   state- 
ment of  its  inventor,  to  traverse  the  remainder  of  the  canal  to  the  meatus 
without  liindrance,  unless  some  abnormal  contraction  be  present. 

But  here  comes  up  a  question  :  Is  a  normal,  liealthy  urethra  always 
uniform  in  its  calibre  in  its  spongy  [)ortion,  and  must  every  irregularity 
which  can  be  detected  by  the  urethrometer  be  regarded  as  an  evidence  of 


'  Dublin  Q.  J.  M.  Sc,  Nov.  1873. 

2  Dr.    Otis's   scale   in   millimetres  of  circumference   differs    somewhat    froiii    the 
Charriire-fiUhre,  or  French  scale.     (See  p.  280) 

3  New  York  M.  J.,  April,  1876. 

19 


290  STRICTURE    OF    THE    URETHRA, 

disease,  or  are  constrictions  (or  obstructions)  in  this  jjortion  of  the  canal 
to  some  extent  independent  of  disease  and  consistent  with  a  state  ot"  health, 
or,  in  a  word,  normal'?  My  own  opinion  is  most  decidedly  in  favor  of  the 
latter  view.  Those  who  maintain  the  contrary  are  logically  forced  to  the 
conclusion — which  they  readily  admit — that  every  obstruction  that  can 
be  detected  by  the  urethrometer,  even  in  the  absence  of  present  inconve- 
nience, requires  internal  urethrotomy,  for  fear  of  some  eventual  ill  effect. 
Such  is  not  my  opinion.  The  two  sides  of  this  question  were  well  pre- 
sented in  a  discussion  before  the  New  York  County  Medical  Society,  Jan. 
2Jr,  liSTG,  and  at  its  subsequent  meeting,  by  Dr.  Otis  on  the  one  hand, 
and  Drs.  Sands  and  Weir  on  the  other.  A  report  of  the  same  may  be 
found  in  the  columns  of  the  New  York  Med.  Journ.  for  April,  1876. 

Dr.  Weir,  a  most  able  and  conscientious  observer,  formulates  his  conclu- 
sions, in  which  I  fully  concur,  as  follows: 

1.  The  spongy  portion  of  the  urethra  is  the  smallest  (except  the 
meatus)  and  least  dilatable  portion  of  the  canal. 

2.  Normal  constrictions  (or  obstructions)  ai-e  to  be  met  with  in  this  por- 
tion of  the  canal  as  small  certainly  as  No.  29,  and  the  means  at  present  re- 
sorted to  are  insufficient  for  the  differentiation  of  such  from  "  strictures  ot 
large  calibre." 

3.  The  healthy  urethra  in  this  portion  can  generally  be  readily  and 
safely  dilated  up  to  an  average  size  of  32  millimetres. 

4.  Tlie  normal  size  of  the  meatus  is  from  No.  21  to  28. 

5.  Tlie  urethral  canal  is,  in  the  words  of  .Jarjavay,'  "  narrow  at  the 
meatus,  dilated  in  the  glans,  and  very  slightly  narrowed  at  tiie  termination 
of  the  fossa  navicularis  ;  then  it  formsia  cylinder  nearly  uniform  to  the  pre- 
pubian  angle,  where  a  coarctation  is  found.  It  enlarges  then  to  the  bulb," 
etc. 

It  may  be  remarked  that  somewhat  more  pain  and  uneasiness  are  occa- 
sioned by  the  urethrometer  than  by  the  use  of  an  ordinary  sound  or  bougie 
a  loide,  and  a  few  drops  of  blood  are  likely  to  follow  the  withdrawal  of  the 
instrument. 

Introduction  of  the  Catheter. — A  catheter  may  be  introduced  while  the 
patient  is  in  the  standing  or  sitting  posture,  but  the  recumbent  position  is 
on  many  accounts  the  best ;  the  patient  lying  s(iuare  on  the  back,  with  the 
shoulders  elevated,  the  knees  di-awn  up  and  somewhat  separated,  the  geni- 
tal organs  entirely  exposed,  and  the  surgeon  standing  or  sitting  on  hisleft.^ 
The  operator  now  raises  the  penis  to  an  angle  of  about  sixty  degrees  with 
the  body,  thereby  effacing  the  anterior  curve  of  the  urethra,  by  means  of 
the  ring  and  middle  finger  of  the  left  hand,  its  [)alm  looking  upwards;  the 

•  Recherches  aiiatomiqiies  sur  1'  niethre,  185(3,  p.  208. 

2  Tliis  is  the  position  usually  recommenrled,  but  much  depends  upon  the  liabit  of 
each  surgeon.  For  myself,  I  prefer  to  be  on  the  patient's  right,  and  to  introduce 
the  instrument  as  far  as  the  bnlb  with  its  convexity  facing  the  pubes,  when  by 
rotating  the  shaft  round  towards  the  abdomen,  the  point  readily  slips  into  the 
membranous  jjortion.  This  method,  called  the  "  tour  de  maitre,^'  has  been  said  to 
be  "  dangerous,"  but  on  what  grounds,  I  have  yet  to  learu. 


INTRODUCTION    OF    THE    CATHETER 


291 


thumb  and  forefinjrer  are  thus  left  free  to  retract  the  prepuce  and  separate 
the  lips  of  the  meatus.  The  catheter,  previously  warmed  and  oiled/  is 
held  tightly  between  the  thumb  and  fore  and  middle  fingers  of  the  right- 
hand,  "like  a  pen,"  its  shaft  corresponding  to  the  fold  between  the  abdo- 
men-and  the  left  thigh.  The  introduction  of  the  instrument  should  be  slow 
and  with  the  exercise  of  little  force;  its  own  weight  is  almost  sufficient  to 
effect  its  passage  if  properly  directed;  if  any  obstruction  be  met  with,  the 
instrument  should  be  withdrawn  for  a  short  distance  and  again  advanced 
with  the  direction  of  its  point  slightly  varied,  or  if  the  obstacle  be  due  to 
spasmodic   contraction  of  tlie   urethra,  it   may  generally  be   overcome  by 


Fig.  77. 


First  stt'p  in  intioduciug  a  ciUlieter.     {Voilleinier.) 

gentle  pressure  continued  for  a  moment  or  two;  while  i)assing  throuo-h  the 
first  two  inclies  of  tlie  uretlira  the  point  of  the  instrument  is  inclined  to  tiie 
lower  surface  in  order  to  avoid  tiie  lacuna  magna  ;  beyond  this  it  should  be 

'  Vaseline,  with  tlu;  ailditicm  of  ten  grains  of  carholic  acid  to  eaeh  ounce,  is  one 
of  the  host  and  most  convenient  hihricants  for  this  and  other  urethral  instruments. 


292 


STRICTURE    OF    THE    URETHRA. 


directed  rather  to  the  upper  surface  to  escape  the  sinus  of  the  bulb  ;  when 
it  has  penetrated  beneath  the  pubes,  the  shaft  is  brought  round  to  the 
median  line  of  the  body,  and  parallel  to  the  surface  of  the  abdomen  ;  the 
handle  is  now  to  be  elevated  to  a  perpendicular  and,  pressure  being  made 
with  the  disengaged  hand  upon  the  mons  veneris  and  the  root  of  the  penis 
for  the  purpose  of  stretching  the  suspensory  ligament,  be  gently  depressed 
between  the  thighs,  not  foi'getting  meanwhile  to  maintain  a  certain  amount 
of  progressive  motion  in  the  instrument,^  when  the  point  will  usually  glide 
into  the  bladder;  if  any  difficulty  is  met  with  at  this  stage  of  the  proceed- 
ing, it  is  probably  because  the  point  has  caught  in  the  extensible  tissue  of 
the  bulb,  and  the  instrument  should  be  again  raised  to  a  perpendicular  and 
slightly  withdrawn,  and  the  penis  elongated  by  traction  before  the  manoeu- 
vre is  repeated;  fui-ther  assistance  may  be  obtained,  if  necessary,  during 
the  latter  part  of  the  introduction,  by  gently  pressing  against  the  convexity 
of  the  instrument  just  back  of  the  scrotum,  or  by  introducing  a  finger  into 
the  rectum,  ascertaining  the  exact  position  of  the  point  and  guiding  it  for- 
wards and  upwards  against  the  posterior  surface  of  the  symphysis;  the 
passage  of  the  extremity  over  the  uvula  vesicte  is  often  indicated  by  nausea 
or  a  slight  tremor  on  the  part  of  the  patient,  and  its  entrance  into  the 
bladder  by  a  flow  of  urine. 


Fig.  78. 


Second  step  iu  introduciii!,'  a  catheter.     (Voillemier. 


Let  us  review  these  several  steps,  and  notice  the  chief  natural  obstacles 
which  are  to  be  avoided.  The  first  is  the  lacuna  magna  situated  upon 
the  upper  surface  of  the  urethra ;  this  is  to  be  shunned  by  directing  the 


'  "The  great  art  in  passing  a  sound  consists  in  properly  combining  the  motion 
of  reversion  with  tliat  of  progression  imparted  to  the  instrument."    (Voillemier.) 


INTRODUCTION    OF    THE    CATHETER.  293 

point  of  the  instrumerit  towards  the  lower  surface  during  the  first  two 
inches  of  its  passage.  The  second  is  the  symphysis  pubis,  against  which 
the  extremity  will  imi)inge,  if  the  abdomen  be  distended  and  the  handle 
be  held  in  the  median  line ;  hence  the  direction  to  hold  the  shaft  parallel 
to  the  fold  of  the  thigh,  and  not  to  bring  it  to  the  median  line  or  ele%'ate 
it  until  the  point  has  penetrated  beneath  the  symphysis.  The  third  is  the 
sinus  of  the  bulb  ;  the  urethral  wall  is  here  very  extensible,  and  is  readily 
thrown  into  a  fold  upon  which  the  point  of  the  instrument  catches  instead 
of  passing  through  the  opening  in  the  triangular  ligament  into  the  mem- 
branous portion ;  this  is  less  likely  to  happen  if  the  tissues  be  stretched  by 
traction  upon  the  penis;  and,  if  it  occur,  the  point  is  to  be  disengaged  by 
slightly  withdrawing  it,  and  afterwards  advanced  in  a  direction  moi'e  to- 
wards the  upper  surface  of  the  canal.  It  is  to  be  observed  that  this  is 
the  only  stage  of  the  process  in  which  traction  upon  the  penis  is  desirable; 
after  the  point  has  entered  the  membranous  portion,  it  is  positively  inju- 
rious. Again,  hypertrophy  of  the  prostate  or  abnormal  development  of 
the  uvula  vesicae  may  oppose  an  instrument  in  the  last  part  of  its  passage ; 
this  is  to  be  avoided  by  depressing  the  handle  and  thus  elevating  the 
point  towards  the  symphysis :  in  these  cases  a  prostatic  catheter  is  often 
required. 

In  using  a  flexible  filiform  bougie,  the  fact  that  it  has  passed  the  stric- 
ture and  entered  the  bladder  may  be  known  by  our  ability  to  insert  it  up 
to  the  handle,  and  to  give  it  a  to-and-fro  motion  Avith  perfect  freedom. 

It  is  a  golden  rule  in  every  case  of  suspected  stricture  to  make  the  first 
examination  with  an  instrument  suflUciently  large  to  distend  the  urethra, 
whatever  history  of  his  previous  symptoms  may  be  furnished  by  the 
patient ;  in  this  manner  many  sources  of  error  already  indicated  will  be ' 
avoided.  The  difference  in  the  impression  conveyed  to  the  hand  of  the 
operator  by  mere  spasmodic  contraction  of  the  urethra  and  an  organic 
stricture,  is  very  marked,  but  can  be  better  felt  than  described.  In  the 
former  case,  the  tissues  against  which  the  point  of  the  instrument  impinges 
evidently  preserve  their  natural  suppleness,  and  the  obstruction  yields  to 
gentle  and  continued  pressure ;  while  in  the  latter,  a  firm  resilient  obstacle 
is  felt,  which  can  be  thrust  backwards,  im|)arting  more  or  less  motion  to 
all  the  surrounding  parts ;  and  if,  after  a  trial  of  one  or  more  smaller  in- 
struments, one  be  found  which  can  be  successfully  introduced  witliin  the 
stricture,  it  is  grasped  or  "  held"  by  it  in  a  very  characteristic  manner. 
This  can  be  only  very  imperfectly  simuhited  by  any  contraction  of  tlie 
voluntary  and  involuntary  muscles  surrounding  the  membranous  portion 
of  the  urethra  which  are  sometimes  called  into  action,  especially  in  irri- 
table subjects,  by  the  presence  of  a  foreign  body,  and  it  requires  but  little 
practice  to  make  the  distinction.  Moreover,  in  spasmodic  contraction,  a 
full-sized  sound  can  be  introduced  witli  a  little  gentle  coaxing,  and,  if 
allowed  to  remain  a  short  time,  is  found  to  be  freely  moval)le. 

Strictures  of  the  urethra  anterior  to  tlie  scrotum  are  sometimes  appre- 
ciable from  the  surface  in  consequence  of  the  amount  of  firm  deposit  which 
surrounds  them  ;  and  external  as  well  as  internal  examination  is  always 


294  STRICTURE    OF    THE    URETHRA. 

desirable  in  order  to  ascertain  the  presence  of  any  sinus  or  abscess  in  the 
neighborhood  of  the  canal. 

However  simple  the  introduction  of  a  sound  or  catheter  may  appear  to  be, 
and  however  simple  it  really  is  in  most  instances  to  a  practised  hand,  yet 
cases  now  and  then  occur  in  which  the  most  able  surgeons  meet  with  diffi- 
culty or  are  completely  foiled  on  the  first  trial.  The  evident  rule  in  such 
cases  is  to  be  sure  to  do  no  harm  and,  if  necessary,  jjutieiitly  to  wait. 

Treatment. 

Constitutional  Means The  constitutional  management  of  stricture 

must  of  course  vary  in  different  cases.  It  is  sufficient,  in  most  cases,  to 
prescribe  such  measures  as  will  best  promote  the  health,  and  place  the 
system  in  the  most  favorable  general  condition.  An  indication  of  the 
highest  importance  is  to  lighten  the  duty  imposed  upon  the  kidneys,  and 
render  the  urine  bland  and  unirritating  to  the  infiamed  suifaces  over  which 
it  passes;  and  this  is  to  be  chiefly  accomplished  by  regulating  the  character 
and  quantity  of  the  food,  and  favoring  depuration  of  th(!  blood  through  other 
channels,  as  the  skin,  bowels,  and  lungs.  The  diet  should  be  simple  but 
sufficiently  nourishing  ;  stimulants,  and  especially  effervescing  stimulants, 
as  champagne  and  beer,  highly  seasoned  food,  cheese,  cabbage,  salt  meats, 
strong  coffee,  and  all  articles  which  tend  to  load  the  urine  should  be  avoided  ; 
the  bowels  should  be  opened  daily,  if  necessary,  by  gentle  laxatives,  but 
violent  purges  are  to  be  avoided.  The  skin  should  be  stimulated  by  frequent 
bathing  and  friction  ;  when  there  is  much  irritability  of  the  urethra,  the 
hot  hip-bath  will  be  found  very  beneficial ;  no  more  exercise  should  be 
taken  than  is  sufficient  to  maintain  the  appetite  and  strength ;  and  in  general 
the  patient  should  lead  a  quiet  and  regular  life.  When  the  urine  is  alkaline, 
or  contains  an  undue  quantity  of  lateritious  deposit,  great  benefit  wmU  be 
derived  from  the  compounds  of  potash  and  soda  with  the  vegetable  acids, 
as  the  citrate  and  acetate  of  potash,  and  tartrate  of  soda  and  potash,  etc. 
Sir  Henry  Thompson  recommends  benzoic  acid  in  these  cases. 

Probably  no  class  of  affections  has  more  thoroughly  taxed  the  ingenuity 
of  surgeons  to  discover  some  speedy  and  effectual  method  of  cure,  than 
have  strictures ;  and  a  volume  might  be  filled  with  the  different  operative 
procedures  which  have  been  proposed  for  this  purpose  ;  but  the  limits  of 
this  chapter  require  that  I  should  confine  myself  to  the  strictly  prac- 
tical, and  speak  of  those  methods  only  which  have  stood  the  test  of  ex- 
perience. 

Dilatation Numerous  explanations  have  been  given  of  the  mode  of 

action  of  dilatation,  but  the  one  now  generally  received,  and  which  is 
probably  correct,  is,  that,  so  far  as  it  effects  any  permanently  good  result, 
it  acts  by  promoting  absorption.  The  presence  of  a  bougie  Avithin  a  stric- 
ture may  mechanically  dilate  its  w^alls,  but  sooner  or  later  after  the  with- 
drawal of  the  instrument,  the  plastic  matei'ial  again  contracts;  and  all  the 
phenomena  attendant  upon  dilatation  show  that  it  accomplishes  something 


DILATATION.  295 

more  than  tins,  and  that,  like  pressure  elsewhere,  it  possesses  the  power  of 
producing  absorption  of  inflammatory  deposits.  At  an  early  period  of  the 
existence  of  stricture,  before  its  constituent  elements  have  become  firmly 
organized,  there  is  reason  to  believe  tliat  they  may  be  entirely  removed 
by  the  treatment  now  under  consideration ;  at  a  later  stage,  a  portion  only 
can  be  thus  dissijiated,  and  it  is  in  these  cases  especially  that  we  are  forced 
to  be  content  with  palliating  the  evil  by  mechanically  enlarging  the  canal 
from  time  to  time,  or  to  resort  to  rupture  or  urethrotomy. 

With  regard  to  the  instruments  employed  in  dilatation  we  are  in  many 
instances  limited  to  fine  flexible  bougies,  because  these  alone  can  be  made 
to  pass  the  obstruction,  and,  as  previously  stated,  flexible  instruments  are 
advisable  in  all  cases  wliich  will  not  admit  a  sound  as  large  as  No.  12 
(Frencli).  In  less  contracted  cases,  the  unyielding  material  of  metallic 
instruments  gives  them  the  advantage  of  not  being  indented  by  tlie  firm 
walls  of  indurated  strictures;  and  being  inflexible  they  are  entirely  under 
the  control  of  the  operator  and  can  be  guided  with  precision  in  any  desired 
direction ;  in  all  cases  complicated  with  false  passages  they  should  un- 
doubtedly be  preferred.  On  the  other  hand,  although  no  instrument  can 
be  made  to  glide  into  the  bladder  moi-e  gently  and  safely  than  a  well- 
polished  or  nickeled  steel  sound,  yet  when  used  by  persons  of  little  experi- 
ence in  urethral  exploration,  it  may  occasion  much  suffering  and  inflict 
serious  injury;  such  persons,  whether  incompetent  surgeons,  or  patients 
practising  upon  themselves,  without  previous  instruction,  should  only  make 
use  of  the  flexible,  bulbous-pointed,  French  bougies  previously  described. 

The  same  method  should  be  followed  in  performing  dilatation  as  in  ordi- 
nary catheterism.  If  the  first  instrument  employed  will  not  enter  the 
obstruction,  a  second  and  smaller  one  must  be  tried;  the  dimensions  of 
the  stream  of  urine  indicating  by  approximation  the  actual  size  required. 
All  attempts  to  penetrate  the  narrowed  ciiannel  should  be  made  with  the 
utmost  gentleness,  and  any  sudden  thrusting  of  the  instrument  avoided; 
force  is  only  admissible  when  the  point  is  felt  to  be  "held,"  thereby  indi- 
cating that  it  is  already  engaged  in  the  passage,  and  even  then  pressure 
must  be  steady,  only  very  gradually  increased,  and  always  moderate.  False 
passages  are  usually  found  below  or  at  the  sides  of  the  urethra;  hence,  if 
tliere  be  any  reason  to  suspect  their  presence,  the  extremity  of  the  instru- 
mcmt  should  be  carefully  guided  along  the  ui)per  surface.  It  often  hap|)ens, 
however,  that  the  orifice  of  the  stricture  is  eccentric,  being  above  or  below, 
or  to  one  side  of  the  centre  of  the  canal;  if  therefore  previous  attempts 
have  proved  unsuccessful,  the  direction  of  the  instrument  may  be  varied; 
or,  if  a  bougie  be  used,  it  may  be  turned  on  its  axis  at  the  same  time  that 
it  is  gently  pressed  forwards.  Assistance  is  sometimes  afforded,  especially 
in  strictures  of  tlie  spongy  and  bulbous  portions,  by  passing  the  disengaged 
hand  down  externally  to  the  seat  of  the  obstruction  and  exercising  a  cer- 
tain degree  of  pressure.  In  cases  of  extreme  dilHculty,  Sir  Henry  Thomp- 
son recommends  that  the  urethra  should  first  be  freely  injected  with  olive 
oil,  which  is  to  be  retained  by  compression  of  the  meatus  while  a  small 
instrument   is   passed;    he   believes    that    thus   the   strictui-e  is   not  only 


296  STRICTURE    OF    THE    URETHRA. 

thoroughly  hibricated,  but  also  somewhat  dilated  by  the  mechanical  pres- 
sure of  the  Huid,  and  states  that  this  metiiod  has  proved  of  very  decided 
advantage  in  his  hands. 

A  tight  stricture  may  foil  our  efforts  on  tlu;  first  trial,  in  which  case  the 
attempt  should  not  be  renewed  for  at  least  three  or  four  days,  or  until  all 
inflannnatory  reaction  has  ceased.  With  patience  and  perseverance,  success 
may  often  be  obtained  after  a  number  of  sessions,  even  five  or  six.  The 
endoscope  may  afford  valuable  assistance,  as  in  several  cases  reported  by 
Prof.  R.  F.  Weir.'  The  endoscopic  tube  is  to  be  crowded  down  firmly 
upon  the  surface  of  the  stricture;  then  on  making  traction,  by  grasping 
the  penis  tight  enough  to  prevent  the  tube  from  slipping,  a  funnel-shaped 
depression  is  formed,  into  the  bottom  of  which  a  filiform  bougie  is  passed 
and  there  held  while  the  endoscopic  tube  is  withdrawn.  The  bougie,  being 
thus  supported  by  the  urethral  walls,  can  now,  in  many  cases,  be  readily 
passed  on  into  the  bladder. 

In  cases  of  tight  stricture,  accompanied  by  hypera^sthesia  or  spasm,  an 
ana3sthetic  is  desirable. 

The  length  of  time  that  an  instrument  should  be  retained  will  depend 
somewhat  upon  the  sensitiveness  of  the  canal.  Mr.  Thompson  recommends 
that  it  should  be  immediately  withdrawn.  I  am  in  the  habit  of  leaving  it 
in  for  from  two  to  five  minutes.  The  phenomena  following  the  passage  of 
an  instrument  tlirough  a  stricture  have  been  carefully  studied  by  Sir  Henry 
Thom|)Son,  and  are  both  highly  interesting  and  instructive.  At  the  first 
succeeding  act  of  micturition,  the  stream  of  urine  is  found  to  be  increased 
in  size:  in  the  course  of  a  few  hours  it  diminishes,  and  is  even  smaller 
than  before  the  introduction  of  the  instrument;  finally,  after  a  day  or  two, 
it  is  permanently  enlarged.  Thompson  attributes  the  first-mentioned  effect 
to  mechanical  dilatation;  the  second  to  reactive  congestion  and  spasm;  and 
the  third  to  the  subsidence  of  the  latter,  and  to  the  removal  by  absorption 
of  a  portion  of  the  organic  deposit.  Tiie  practical  deductions  from  these 
observations  are:  that  an  instrument  should  not  be  inserted  with  such 
force,  nor  retained  so  long,  as  to  excite  decided  inflammatory  action  ;  and 
that  cathcterism  should  not  be  re[)eated  until  the  irritation  produced  by 
previous  a[)j)lications  has  disappeared. 

An  interval  of  from  two  to  five  days  between  the  applications  is  usually 
sufficient.  At  the  second  visit,  tlie  instrument  first  employed  may  be 
introduced  for  a  moment,  then  withdrawn,  and  the  next  larger  size  inserted. 
Tiius  by  a  gradual  advance,  the  stricture  may  be  enlarged  to  a  calibre 
corresi)onding  with  that  of  the  external  meatus,  but  not  to  the  original  size 
of  the  constricted  portion  of  the  canal,  unless  the  unyielding  ring  of  the 
meatus  be  slit  up.  This  should  be  done,  unless  the  meatus  is  unusually 
patent,  and  the  dilatation  then  be  continued  until  an  instrument  equal  in 
size  to  the  normal  calibre  of  the  urethra,  as  measured  by  the  urethrometer, 
can  be  freely  [)assed ;  in  short,  dilatation  to  the  fullest  extent  is  to  be 
recommended.      Under  no  circumstances  should  cathcterism  be  at  once 

'  Am.  J.  Syph.  &  Derm.,  N.  Y.,  1870,  vol.  i,  p.  34. 


CONTINUOUS    DILATATION.  297 

abandoned  so  soon  as  the  stricture  is  dilated  to  the  desired  extent,  what- 
ever tliat  may  be ;  but  the  patient  should  be  taught  how  to  pass  instruments 
himself  and  be  directed  to  use  them  once  a  week  for  several  months  and 
at  gradually  increasing  intervals  for  the  remainder  of  his  life.  Any  future 
tendency  to  contraction,  as  evinced  by  trial,  should  warn  him  that  the 
subsequent  treatment  has  not  been  faithfully  carried  out. 

Conthmous  Dilatation} — A  more  expeditious  mode  of  dilating  stricture 
is  by  the  method  known  as  "  continuous  dilatation,"  in  which  a  catheter, 
if  it  can  be  introduced,  is  retained  for  a  considerable  length  of  time,  gene- 
rally for  several  days  in  succession.  In  the  course  of  twenty -four  or  forty- 
eight  hours,  a  purulent  discharge  appears,  proceeding  from  the  seat  of  the 
obstruction,  and  the  [)assage  is  rapidly  enlarged  ;  other  instruments  gradu- 
ally increasing  in  size  are  then  successively  introduced,  until  the  desired 
amount  of  dilatation  be  attained.  Xo  one  instrument  should  be  left  in  for 
more  than  forty-eight  hours,  lest  it  become  incrusted  with  calculous  deposit 
or  cause  deep  ulceration  of  the  urethral  walls. 

This  practice  is  not  to  be  recommended,  unless  when  from  any  cause, 
as  for  instance  the  presence  of  false  passages,  the  difficulty  already  experi- 
enced in  introducing  a  catheter  has  rendered  it  probable  that  it  cannot  be 
reinserted  if  once  withdrawn.  Continuous  dilatation  is  likely  to  be  attended 
with  untoward  symptoms  and  is  always  followed  by  a  strong  tendency  to 
recon traction.  I  never  resort  to  it  except  to  the  slight  extent  of  enlarging 
the  canal  sufficiently  to  enable  me  to  pass  the  shaft  of  some  instrument 
intended  for  internal  urethrotomy  or  rupture. 

Witliin  the  last  few  years,  several  attempts  have  been  made  to  revive 
continuous  dilatation,  and  have  acquired  some  temporary  notoriety;  one 
by  ]\I.  Le  Fort,^  and  another  by  M.  Corradi,^  of  Florence.  Althougii  the 
names  ap[)lied  by  these  authors  to  their  methods  would  lead  one  to  suppose 
them  to  be  new,  the  process  is  essentially  the  same  as  that  already  mentioned, 
and  is  to  be  judged  as  such.  An  interesting  paper  on  Corradi's  method  is 
to  be  found  in  the  thesis  of  M.  Bos.* 

^'Over  Distention" — Mr.  Thompson  applies  this  name  to  a  method 
which  does  not  differ  from  that  heretofore  known  as  "rapid  dilatation," 
except  that  the  instrument  employed  by  him  permits  distention  to  be  car- 
ried beyond  the  size  which  the  meatus  of  the  urethra  will  admit.  The 
action  of  this  instrument  will  be  readily  understood  from  Fig.  79.  Mr. 
Thompson  describes  as  follows  the  manner  of  using  it : — 

"  The  method  of  applying  the  power  by  this  instrument  differs  materially 
from  that  in  others,  in  being  made  slowly  (better,  therefore,  under  the 
influence  of  chloroform),  so  that  from  seven  to  ten  minutes  are  occupied 

« 

*  "Dilatation  perinan<»nte"  of  the  French. 

*  Malgaioxk,  M6i1.  operat.,  edit.  Lk  Fokt,  187.'),  p.  507. 

3  See  Bkoca,  Rapport  sur  la  prix  d'Argenteuil,  Bull,  do  I'Acad.  de  med.,  Paris, 
t.  xxxiv,  p.  1215. 

*  De  la  dilatation  rapide  des  r^trecissements  de  ruretlire,  Tlie.se  inaugurale, 
Paris,  1876. 


298 


STRICTURE    OF    THE    URETHRA. 


in  slowly  reaching  the  maximum  point  of  distention  ;  the  ohject  being  to 
overstretch  the  morbid  tissues  as  much,  and  to  rupture  them  as  little,  as 
possible,  in  order  to  destroy,  or,  at  all  events,  to  greatly 
Fig.  "0.  impair,  the  natural  tendency  of  the  sti'icture  to  contract. 

Before  operating,  the  distance  of  the  stricture  from  the 
external  meatus  is  measured  by  passing  a  full-sized 
bougie  down  to  the  stricture ;  the  slide  is  then  placed 
upon  the  figure  which  denotes  that  distance.  The 
instrument  is  passed  until  the  slide  aiTives  at  the 
meatus  ;  when  the  maximum  distention  is  reached,  the 
screw  is  turned  back  a  little,  so  as  not  to  close  the 
blades ;  the  instrument  is  withdrawn  ;  a  full-sized  gum 
catheter  is  passed,  and  allowed  to  remain  twenty-four 
hours.  On  the  third  day  after  the  operation,  a  large 
metallic  sound  is  passed,  and  subsequently  at  longer 
intervals.  If  it  is  preferred  to  rupture  instead  of  to 
distend  to  the  same  degree,  the  handle  must  be  turned 
rapidly,  and  in  a  few  seconds  the  full  size  named  can 
be  obtained." 

I  find  it  difficult  to  reconcile  Mr.  Thompson's  com- 
mendation of  this  practice  with  what  he  says  in  the 
next  sentence  when  speaking  of  "  rapid  dilatation  :" 
"  Tliis  term  and  the  practice  it  describes  may  now  lapse 
into  oblivion.  The  proceeding  by  rupture,  whatever 
else  it  may  do,  must  of  necessity  render  wholly  unneces- 
sary any  resort  to  the  violent  measures  employed  as 
rapid  dilatation!" 

I  have  reason  to  believe  that  this  instrument  is  rarely 
used  at  the  present  time,  even  by  its  inventor. 

In  concluding  the  remarks  upon  this  method  of 
treatment  I  desire  to  say  that  gradual  dilatation 
should  be  selected  as  the  safest  and  best  method  of 
treatment  for  the  majority  of  strictures,  especially  when 
seated  at  a  greater  depth  than  four  inches  from  the 
meatus.  As  we  shall  see  presently,  it  is  not  as  well 
adai)ted  for  strictures  of  the  pendulous  portion  of  the 
penis;  but  even  here  the  general  practitioner,  wlio  is 
not  familiar  with  urethral  surgery,  should  not  hastily 
abandon  this  method  of  treatment  in  favor  of  the  more 
dangerous  ones  which  we  have  yet  to  describe. 

Internal   Incision   and   Rupture — There   are 

certain  considerations  connected  with  these  two  methods 

of  treatment  which,  in  order  to  avoid  repetition,  it  may 

be  well  to  take  up  at  the  outset. 

The  nearer  a  stricture  is  situated  to  the  external  meatus,  the  less  the 

dano-er,  as  a  general  rule,  from  operative  interference.     Strictures  witliin 


INTERNAL    INCISION    AND    RUPTURE. 


299 


Fijr.  80. 


three  inches  of  the  external  orifice,  and  especially  those  at  the  meatus,  are  so 
unyielding,  and  reoontract  so  readily,  that  incision  becomes  desirable.  In 
the  subpubic  curvature  the  vascularity  of  the  tissues  would  seem  to  call  for 
rupture  in  preference  to  internal  urethrotomy,  and  in  practice,  the  former 
will,  as  a  rule,  be  found  to  be  the  safer  operation. 

There  was  formerly  a  radical  defect  in  most  instruments  intended  to 
operate  upon  urethral  strictures  from  within  the  canal.  I  refer  to  the  large 
size  of  the  shaft  of  the  instrument,  which 
rendered  it  impossible  to  employ  them  in  very 
tight  strictures,  and  hence  these  instruments 
were  open  to  the  grave  objection  that  a  quarter 
or  more  of  the  treatment  must  first  be  accom- 
plished by  dilatation  before  they  could  be  used. 
Two  inventions  obviate  this  difficulty  in  an 
admirable  manner,  and  enable  us  to  make  use 
of  either  rupture  or  internal  incision  in  any 
case  of  stricture  through  tvhich  any  bougie, 
hotoever  small,  can  be  passed. 

In  one  of  these,  original  with  that  eminent 
surgeon.  Prof.  AVm.  H.  Van  Buren,  M.D.,  the 
extremity  of  the  urethral  instrument  is  per- 
forated like  a  canula  for  a  short  distance,  say 
the  eighth  of  an  inch,  from  its  tip,  with  a 
groove  extending  further  up  the  shaft,  so  tliat 
the  instrument  may  be  introduced  threaded, 
as  it  were,  upon  a  fine  bougie  previously  in- 
serted (Fig.  80). 

This  invention,  while  commending  itself  by 
its  simplicity,  is  only  adapted  to  whalebone 
bougies  ;  gum  bougies  are  too  flexible  to  serve 
as  the  guide  ;  and  since  the  latter  can  often  be 
I)assed  through  strictures  in  the  subpubic  por- 
tion of  the  canal,  when  the  former  cannot,  the 
use  of  this  device  is,  I  think,  limited. 

In  tiie  other  plan,  a  flexible  bougie  is  pro- 
vided with  a  metallic  cap  which  screws  on  to 
the  extremity  of  the  instrument  (Fig.  81). 
The  bougie  may  be  of  any  degree  of  fineness; 
if  its  point  can  be  introduced  through  the  stric- 
ture and  retained  for  a  short  time,  the  main 
pd/tion  of  the  stem  will  soon  follow ;  the 
metallic  shaft  is  then  screwed  upon  tlie  bougie 
and  passed  into  the  bladder,  when  the  stricture 
is  completely  under  the  control  of  the  operator. 

In  my  own  practice  I  have  extended  the  use 
of  this  plan  by  providing  my  urethral  case  of  instruments  with  a  dozen  or 
more  flexible  gum  bougies  of  various  degrees  of  fineness  all  of  them  armed 


300  STRICTURE    OF    THE    URETHRA. 

with  metallic  screws,  any  one  of  which  will  fit  the  extremity  of  either  of 
the  instruments  I  most  frequently  employ  for  the  purpose  of  rupture  or 
internal  incision,  and  which  may  also  serve  as  a  guide  for  a  catheter  to 
draw  off  the  urine.     This  plan  is  only  objectionable  because  it  requires  a 

Fig.  81. 


IIEMANN-CO-NV 


degree  of  nicety  in  the  adjustment  of  the  screw-tips  which  few  instrument- 
makers  will  give  unless  carefully  watched  and  driven  up  to  the  mark  ;  but 
it  is,  I  believe,  the  best,  and  is  of  extended  application. 

These  devices,  and  especially  the  latter,  enable  us  to  seize  the  oppor- 
tunity  foi-  an  operation.  Strictures  are  not  at  all  times  equally  i)ermeable. 
We  may  "get  through"  one  day  and  not  another.  If  a  special  day  and 
hour  be  appointed  for  the  operation,  unexpected  difficulties  will  often  be 
met  with.  When  a  difficult  case  of  stricture  presents  itself  and  the  first 
trial  fails  to  pass  the  contraction,  time  and  patience  are  the  first  requisites. 
Haste  is  almost  sure  to  do  harm.  Let  the  exploration  be  repeated  at 
proper  intervals,  always  with  flexible  bougies  armed  with  screws  available 
when  the  opportunity  offi^rs  ;  then  when,  thanks  to  skill  and  chance,  the 
contraction  is  passed,  the  choice  of  the  operation,  whether  rupture  or  in- 
cision, is  left  to  the  operator.  AVhichever  instrument  he  prefers  may  be 
attached  to  the  bougie,  which  is  coiled  up  in  the  bladder  as  the  shaft  is 
made  to  advance,  and  the  patient  is  relieved  of  his  distress  upon  the  spot 
by  a  rupturing  tube  or  incising  blade. 

Tliere  are  certain  considerations  pertaining  to  the  treatment  before  and 
after  the  operation,  whether  by  rupture  or  incision,  which  may  as  well  be 
mentioned  here. 

No  one  should  think  of  operating  upon  a  stricture,  unless  in  case  of 
special  emergency,  while  the  patient  is  depressed  from  any  cause.  I  find 
that  many  patients  from  the  South  and  West  are  suffering  with  symptoms 
referrible  to  malarial  influence,  aggravated  probably  by  their  urethral 
trouble,  and  this  condition  should  first  be  removed  by  quinine  and  tonics. 

A  still  more  important  point  is  to  examine  into  the  condition  of  the 
kidneys.  It  should  be  an  invariable  rule  before  operating  in  any  case  of 
stricture,  to  make  one  or  more  thorough  examinations  of  the  urine,  and  to 
note  its  amount  in  the  twenty-four  hours,  its  specific  gravity,  the  presence 
of  albumen,  casts,  etc.  Tlie  importance  of  a  continued  low  specific  gravity 
as  indicative  of  renal  trouble,  even  if  casts  cannot  be  found,  should  not  be 
Ibrgotten.  It  is  almost  needless  to  say  that  any  evidence  of  kidney  dis- 
ease makes  the  prognosis  a  grave  one,  and  should  lead  us  to  avoid  an  ope- 
ration if  possible. 

If  an  operation  be  decided  upon  it  is  best  to  keep  the  patient  quiet  for 
a  few  days  beforehand,  and  to  take  measures  to  have  the  rectum  empty. 
At  the  time  of  the  operation  the  size  of  the  meatus  should  be  carefully 
examined,  and,  if  necessary,  .be  enlarged,  by  the   method  presently  to  be 


INTERNAL    INCISION    AND    RUPTURE. 


301 


described,  to  a  size  corresponding   to    the    supposed  Fig.  82. 

calibre  of  the  urethra,  as  estimated  by  Otis's  rule 
already  given  (see  p.  289). 

Supposing  the  incision  or  rupture  to  have  been 
made,  the  surgeon  is  naturally  inclined  to  explore  the 
canal  by  means  of  bougies  a  boule  or  otherwise,  in 
order  to  ascertain  if  the  desired  result  has  been  fully 
attained,  and  that  no  band  of  stricture  remains.  In 
operating  upon  the  first  three  or  four  inches  of  the 
canal,  this  exploration  may  be  made  within  reason- 
able limits  with  impunity,  and,  indeed,  the  operation 
may  be  repeated  on  the  spot  if  found  necessary.  In 
cases,  however,  of  tight  stricture  at  the  depth  of 
from  four  to  five  and  a  half  inches,  T  am  satisfied 
that  much  harm  is  often  done  by  such  subsequent 
exi)loration  over  the  raw  surface.  In  these  deep- 
seated  strictures  it  is  far  better  to  remain  satisfied, 
for  the  time  being,  with  the  fact  that  the  divulsing 
tube  or  the  incising  blade  has  been  successfully 
passed,  and  leave  further  exploration  to  a  subsequent 
period.  In  short,  it  is  one  of  those  instances  in 
which  the  old  proverb /(?«</««  lente  is  of  great  value, 
and  in  cases  of  tight  stricture,  especially  when  deep- 
seated,  it  is  Avell  to  tell  the  patient  beforehand  that 
probably  more  than  one  operation  will  be  required  to 
render  the  result  complete. 

If  the  bladder  was  not  emptied  a  short  time  before 
the  operation,  or  if  the  operation  has  been  prolonged, 
it  is  now  well  to  draw  off  the  urine,  so  that  any  further 
call  to  mictiu-ate  may  be  delayed  as  long  as  possible. 
For  this  puri)0se  we  may  employ  an  ordinary  catheter, 
or,  uuder  those  circumstances  just  mentioned,  when 
the  repeated  introduction  of  instruments  is  undesira- 
l)le,  a  fine  catheter  (Fig.  82)  may  be  screwed  to  the 
bougie-conductor  without  withdi-awing  the  latter  from 
the  Ciiiial  any  further  tlian  is  necessary  to  detach  the 
metallic  shaft  of  the  instrument  employed  in  the  ope- 
ration. A  steel  stylet  traverses  this  catheter,  in  order 
to  give  it  greater  firmness  and  prevent  the  eye  from 
b^^ing  clogged  with  blood. 

"Many  authorities  advise  that  after  these  operations 
a  catheter  should  be  tied  in  the  bladder,  and  retained  for  24  or  48  hours. 
I  have  never  done  this  in  my  operations  of  rupture  and  interual  incision, 
and  have  seen  no  reason  to  regret  my  course.  On  the  contrary,  I  believe 
that  patients  do  better  without  this  source  of  irritation.  If  the  permanent 
catheter  be  used,  its  extremity  should  be  left  open  and  connecteil  with  a 
urinal  by  means  of  an  India-rubber  tube.     Even  then  the  urine  is  apt  to 


Author's  catlieter, 
with  scrovv-poiut  so  tliat 
it  iiiiiy  he.  attached  to 
any  (llifonn  liou^'ie  era. 
ployed  in  previous  rup- 
ture or  incision. 


302  STRICTURE    OF    THE    URETHRA. 

dribble  away  by  the  side  of  the  instrument  and  come  in  contact  with  the 
incision,  the  very  thing  that  the  employment  of"  the  catheter  Avas  intended 
to  avoid. 

Before  leaving  the  patient  it  is  desirable  to  introduce  into  the  rectum  a 
suppository  containing  a  quarter  of  a  grain  of  morphia,  and  to  give  by  the 
mouth  one  or  two  drops  of  the  tincture  of  aconite  root,  ordering  its  repeti- 
tion every  two  to  three  hours,  for  the  purpose  of  preventing  urethral  fever. 
This  use  of  aconite,  which  is  certainly  of  great  value,  is  said  to  have  been  fii'st 
suggested  by  ^Ir.  Long.^  The  patient  slioukl  be  directed  to  delay  passing 
his  urine  as  long  as  possible,  and  if  he  should  have  a  chill  on  the  first  act 
of  micturition,  to  take  a  hot  bath.  Rest  in  the  horizontal  posture  is  neces- 
sary for  the  ensuing  twenty-four  hours,  but,  in  most  cases,  is  not  longer 
required. 

His  temperature  should  be  carefully  watched,  since  it  is  found  by  expe- 
rience that  this  is  the  best  test  of  his  condition.  Even  if  all  other  symp- 
toms are  fjxvorable,  a  high  degree  of  temperature  should  lead  us  to  defer 
any  introduction  of  an  instrument.  Much  mischief  is  often  done  by  too 
early  catheterization  after  the  operation,  tiie  surgeon  either  regarding  it  as 
necessary  in  order  to  keep  the  urethra  patent,  or,  perhaps,  mistaking  sup- 
pression of  urine  for  retention.  Nothing  appears  to  be  lost  by  delay,  for 
I  have  found  the  canal  open  after  a  week,  a  fortnight,  and,  in  one  case,  even 
as  late  as  a  montli.  Provided  that  all  goes  on  well,  that  there  are  no  un- 
favorable sym[)toms  as  of  urethral  fever,  and  that  the  temperature  remains 
normal,  we  are  able  to  pass  a  sound  by  the  third  or  fourtli  day,  taking  at 
first  one  of  moderate  size,  and  then  one  as  large  as  the  normal  calibre  of 
the  urethra.  Tiiis  should  be  repeated  every  second  day  at  least,  until  the 
absence  of  blood,  even  if  some  purulent  discharge  still  remains,  indicates 
that  the  wound  has  healed,  and  this  usually  takes  about  a  fortnight. 

In  the  previous  edition  of  this  book  occurs  the  following  passage,  which 
expresses  the  generally  received  opinion  as  to  the  necessity  existing  for 
any  one  who  has  once  had  stricture  to  employ  sounds  at  intervals  for  the 
remainder  of  his  life. 

There  is  no  fact  with  regard  to  stricture  better  worthy  of  remembrance 
than  this,  that  after  any  mode  of  treatment  a  stricture  is  sure  to  return  in 
time,  unless  the  patency  of  the  canal  be  kept  up  by  the  intermittent  use 
of  sounds.  How  often  these  should  be  used  depends  upon  the  amount  of 
tendency  to  contraction,  and  varies  in  different  cases ;  a  safe  rule  is  at  in- 
tervals of  four  days  for  a  month,  then  at  intervals  of  a  week  for  six  months, 
and  finally  at  intervals  of  a  month  or  two  for  years  or  for  the  remainder 
of  life.  But  it  is  not  necessary  or  even  desirable  that  a  patient  should  be 
dependent  for  this  after-treatment  ujjon  a  surgeon  ;  he  should  be  taught 
to  do  it  for  himself,  and  after  a  little  practice  Avill  do  it  better  than  any 
one  can  do  it  for  him  ;  his  instruments  should  be  selected  by  the  surgeon, 
and  he  should  Ije  impressed  with  the  importance  of  his  using  them  faith- 
fully. 

'  Liverpool  M.  Chir.  J.,  .Jan.  1S50. 


INTERNAL    URETHROTOMY. 


303 


There  can  be  no  question  that  the  above  course  should  be  followed  in 
all  cases  which  have  been  treated  by  dilatation  alone.  It  is,  however, 
asserted  by  Otis  and  others  that  the  thorough  division  of  strictures  by  in- 
ternal urethrotomy  effects  a  permanent  cure,  and  that  tlie  canal  will  ever 
remain  free  after  the  operation,  even  if  nothing  lias  been  done  meanwhile. 
I  have  met  with  several  cases  which  would  seem  to  confirm  this  view,  but 
a  sufficient  time  has  not  yet  elapsed  either  in  my  own  cases  or  in  those 
published  by  others,  to  warrant  any  one  in  expressing  a  decided  opinion. 

Internal  Urethrotomy Strictures  at  or  near  the  meatus  were  formerly 

divided  by  means  of  Civiale's  concealed  bistoury  (Fig.  83),  or  by  a  curved 
sharp-pointed   bistoury,  its  point  being  protected  by    wax  on  its    inser- 

Fis.  83. 


Civiale's  concealed  bistoury.    (After  Phillips.) 

tion.  Both  of  these  instruments  are  now  regarded  as  less  desirable  than 
an  ordinary  blunt-pointed  tenotome,  which  affords  the  surgeon  greater  ])re- 
cision  in  making  his  cut.  Prof,  Otis  prefers  one  curved  ;  Prof.  Piffard  one 
straight  as  here  represented  (Fig.  84).     There  is  but  little  to  choose  be 

Fiff.  84. 


tween  these  two  forms.  The  cut  is  always  to  be  made  downwards  or  on 
the  floor  of  the  urethra,  and  the  enlarged  opening  to  be  subsequently  tested 
with  a  bougie  a  bottle  to  ascertain  if  it  be  of  sufficient  size. 

In  practising  this  operation,  which  I  fear  is  becoming  more  common 
than  is  necessary,  there  are  two  points  desirable  to  be  borne  in  mind.  On 
the  one  hand,  the  operation  must  be  done  thoroughly  in  order  to  be  effi- 
cacious. If  th(!  meatus  or  stricture  is  merely  nicked,  the  operation  will 
have  to  be  repeated,  and,  again,  patency  of  the  opening  must  be  secured 
by  the  passage  of  instruments  every  day  or  two  until  the  wound  has 
healed. 

On  the  other  hand,  great  care  should  be  used  not  to  convert  the  meatus 
into  a  hypospadias,  a  result  which  is  excessively  annoying  to  patients  and 
which  is  often  followed  by  a  persistent,  nodular  induration  at  the  inferior 
edge  of  th^  cut. 

In  order  to  prevent  hemorrhage  it  is  well  to  stuff  the  wound  with  styp- 
tic cotton,  which  may  be  allowed  to  remain  until  it  comes  away  spontane- 
ously, and  tlie  urine  is  readily  discharged  above  it.  Should  hemorrhage, 
however,  occur,  it  is  in  a  situation  where  it  may  usually  be  readily  con- 


304 


STRICTURE    OF    T  EI  E    URETURA. 


trolled  by  pressure  or  by  ice.     Dr.  Henry  Dick^  has  invented  an  ingenious 
Sonde -tourniquet  for  this  purpose  (Fig.  85). 


Ficr.  85. 


Dick's  soiide-touriiiquet. 


This  instrument  consists  of  a  urethral  canula  containing  a  plug  which 
is  to  be  withdrawn  on  the  passage  of  the  urine,  and  a  screw-pad  to  effect 
compression  on  the  external  surface  of  the  corpus  spongiosum. 

In   incising   strictures  further  removed   than   those   in  the  immediate 


Fiff.  86. 


Fis.  87. 


Fijr.  88. 


FiL^  St). 


'::^ 


^;: 


.Sections  OF  THE  penis  showing  the  position  of  the  urethra  in  the  corpus  spongiosum 

BETWEEN  THE  QLANS  AND  THE  TRIAN9ULAR   LIOAMENT. 

Fig.  86,  m.  0.010  below  base  of  (,'lans. 

Fig.  87,  m.  0.03.")         "        "        " 

Fig.  88,  m.  0.03.5         "        "        " 

Figs.  89,  90,  91,  from  the  beginning  of  the  end  of  biUbous  portion  of  urethra  to  near  beginning 
of  prostatic  portion,  i.  «.,  to  where  the  overlying  corpus  spongiosum  ends. 

Lines  ah,  sections  of  the  corpus  spougiosuiii,  showing  tlie  relations  of  the  urethra  to  tlie  erec- 
tile tissue.  • 

neighborhood  of  the  meatus,  the  question  arises  whether  the  cut  had  better 
be  made  downwards  or  upwards.      P^ach  method  has  had  its  advocates  and 

•  Subcutaneous  and  Otlier  Methods  of  Dividing  Strictures  of  the  Urethra,  London, 

1878. 


INTERNAL    URETHROTOjMY. 


305 


Fig.  92. 


instruments  have  been  made  accordingly.  Reasoning  from  the  anatomy 
of  the  parts,  there  is  less  danger  of  hemorrhage  when  the  cut  is  made  up- 
wards, since  the  amount  of  vascular  tissue  of  the  corpus  spongiosum  over- 
lying is  much  less  than  that  underlying  the  urethra.  The  accompanying 
wood-cuts,  for  which  I  am  indebted  to  the  kindness  of  Prof.  R.  F.  Weir, 
exhibit  sections  of  the  penis,  at  various  distances  from  the  glans.  They 
represent  the  average  of  the  appearances  presented  in  sections  of  five  penes, 
frozen  in  ice  or  with  gelatine  injected  into  the  spongy  tissue  of  the  three  cor- 
pora. 

Figs.  86  to  91  show  how  much  greater  is  the  thickness  of  the  vascular 
tissue  of  the  corpus  spongiosum  upon  the  floor  than  the  roof  of  the 
urethra.  The  last  one  (Fig.  91)  represents  a  section  at  the  extreme  limit 
of  the  bulb  where  it  rests  against  the  triangular  ligament  and  corresponds 
above  to  the  membranous  urethra.  It  would 
here  appear  that  the  danger  from  a  section 
upwards,  as  we  reach  the  bulbo-membranous 
junction,  is  almost  nil.  It  is  true  that  in 
the  triangle  formed  by  the  junction  of  the 
three  corpora,  two  or  three  veins  are  found 
which  might  possibly  be  opened  in  a  large 
upward  section,  but  the  hemorrhage  from 
them  could  easily  be  controlled.  Since 
tliere  are  no  arguments,  so  far  as  I  am  aware, 
in  favor  of  a  downward  section,  I  believe  the 
above  considerations  should  prevail,  and  lead 
us  to  make  the  section  upwards  in  the 
median  line  in  all  urethrotomies  posterior  to 
the  meatus  and  fossa. 

The  instruments  invented  for  intei'nal 
urethrotomy  are  legion  in  number,  and  we 
have  no  intention  even  to  mention  others 
than  those  we  can  best  recommend.  We 
believe  that  for  all  ordinary  cases  likely  to 
be  met  witii  in  practice,  two  will  be  found 
sutficient,  viz.,  Maisonneuve's  urethrotome 
for  tight  strictures;  Prof.  Otis's  dilating 
urethrotome  for  such  strictures  of  larger 
calibre  as  will  admit  its  shaft. 

Maisonneuve's  urethrotome  consists  simply 
of  a  grooved  staff,  which  need  not  exceed 
No.  7  of  the  French  catheter  scale  (two  and 
one-third  millimetres  in  diameter),  provided 
at  iti  extremity  with  a  screw-point,  to  which 
is  attached  a  filiform  bougie.     The  blades, 

intended  to  slide  in  the  groove  and  to  divide  the  stricture,  are  trianguhir 
in  shape,  sharpened  before  and  behind,  but  blunt  at  the  apex,  so  that  tiiey 
may  jjass  over  the  sound  urethral  mucous  membrane  without  wounding  it. 
20 


Maisonneuve's  uretlirotonie  iiiodiflod. 


306 


STRICTURE    OF    THE    URETHRA. 


I  have  slightly  modifiecl  this  instrument,  and  as  I  think,  with  advantage. 
In  the  original,  the  curve  of  the  shaft  is  a  very  long  one,  necessitated  by 
the  fact  that  the  groove  extends  to  the  point,  and  that  the  blade  cannot 
be  made  to  follow  a  short  curve,  but  the  introduction  of  the  instrument  is 
thereby  rendered  difficult  in  many  cases.  I  liave  consequently  introduced 
the  short  curve  of  Mv.  Thompson,  and  had  the  groove  extend  only  through 
the  straight  portion  of  the  shaft,  which  is  quite  sufficient,  since  whenever 

the  point  has  been  made  to  pass  the 
Fig.  93.  stricture,  the  straight  shaft  with  its 

ff)  r^  groove  will  readily  follow.  (See  Fig. 

«5  ^  IJ  93.) 

I  a  Tlie  manner  of  using  this  instru- 

ment is  very  simple.  In  most  cases 
the  filiform,  flexible  conductor  is  first 
introduced  as  a  guide,  and  the  shaft 
of  the  instrument  is  then  screwed 
upon  it,  and  made  to  follow  it  into 
the  bladder.  In  many  instances,  I 
have  been  able  to  introduce  the  shaft 
alone,  armed  with  the  blunt  point, 
which  is  always  provided,  when  I 
have  found  it  impossible  to  pass  the 
conducting  bougie.  In  either  case, 
when  the  bladder  is  fairly  entered, 
as  may  be  recognized  by  the  finger 
in  the  rectum,  the  penis  is  to  be  put 
upon  the  stretch,  and  the  blade, 
usually  the  largest  in  the  set,  is 
thrust  down  to  the  extremity  of  the 
groove,  dividing  every  obstruction 
before  it.  A  double  incision  of  the 
stricture  is  often  made  by  my  friend, 
Prof.  Weir,  by  rotating  more  or  less 
the  shaft  of  the  instrument  before 
withdrawing  the  blade,  which  then 
cuts  the  stricture  at  a  different  point 
as  it  comes  out.  The  blade  is  now 
withdrawn,  the  bladder  emptied  of 
urine  by  the  catheter,  and  other 
measures  adopted  which  have  already 
been  mentioned. 

M.  Voillemier  objects  to  Maison- 
neuve's  instrument  on  the  ground 
that  it  is  liable  to  wound  the  healthy 
mucous  membrane,  and  instances  the 
case  of  a  patient  who  died  of  cholera  shortly  after  the  operation,  and  in 
whom  the  urethra  was  found  to  be  incised  from  the  meatus  to  the  bladder. 


Voillemier"8  urethrotome. 


INTERNAL    URETHROTOMY. 


307 


He  proposes  to  remedy  this  diflficulty  by  means  of  a  sliield  which  covers 
the  blade  in  its  passage  through  the  healthy  urethra,  and  which  can  be 
withdrawn  as  soon  as  the  stricture  is  encountered.  I  have  used  Maison- 
neuve's  instrument  in  a  large  number  of  cases,  and  have  had  no  reason  to 


Otis's  dilating  urethrotome,  Xo.  3. 


Otis's  dilating  urethrotome,  No.  4. 


believe  that,  when  properly  made,  it  is  open  to  the  objection  urged  ;  more- 
over, on  trial  of  Voillemier's  instrument  I  have  found  it  more  difficult  to 
manage,  and  very  liable  to  get  out  of  order. 


308 


STRICTURE    OF    THE    URETHRA. 


Fig.  96. 


i 


Prof.  Otis  lias  produced  several  dilating  urethrotomes,  known  by  instru- 
ment makers  as  Nos.  1,  2,  3,  and  4.  Woodcuts  of  Nos.  3  and  4,  the  one 
curved  and  the  other  straight,  are  here  given.  The  latter  is  sufficient,  as 
the  instrument  should  only  be  used  in  the  straight  portion  of  the  urethra. 
These  instruments  consist  of  a  pair  of  steel  shafts  connected 
togetlier  by  short  pivotal  bars,  on  the  plan  of  an  ordinary 
parallel  ruler.  They  are  separated  by  means  of  a  screw  at 
the  handle,  near  which  is  a  dial  indicating  the  extent  of 
their  divergence.  Tiie  upper  bar  of  the  instrument  is  tra- 
versed by  a  urethrotome,  terminating  in  a  thin,  narrow, 
spring  blade,  which,  when  at  the  extremity  of  the  groove  in 
which  it  runs,  is  concealed  in  a  slot.  The  instrument,  with 
its  contained  urethrotome,  having  been  passed  down  beyond 
the  site  of  the  stricture  and  dilated  until  the  sti'icture  is 
made  tense,  the  handle  of  the  urethrotome  is  withdrawn, 
causing  the  blade  to  rise  from  the  depression  in  which  it 
was  concealed,  and  the  stricture  is  divided  upon  its  upper 
wall  from  behind  forwards.  The  advantages  claimed  by  its 
inventor  for  this  instrument  are  :  that  it  attacks  a  tense 
instead  of  a  tlaccid  stricture;  that  its  incisions  are  made  at 
a  predetermined  point,  depth,  and  extent ;  that  it  is  espe- 
cially adapted  to  strictures  of  large  calibre ;  and  that  it 
combines  great  strength  with  ease  of  manipulation' — all  of 
which  I  have  found  to  be  true. 

Civiale's  urethrotome  was  for  a  long  time  the  favorite  one 
and  is  still  preferred  by  Sir  Henry  Thompson.  A  glance 
at  the  accompanying  cut  will  be  sufficient  to  understand  its 
construction.  The  terminal  bulb  in  which  the  blade  is  con- 
cealed equals  about  No.  16  or  17  (about  7  or  8  of  the  English 
scale),  and  hence  the  instrument  cannot  be  used  when  the 
passage  is  of  less  size.  The  blade  cuts  from  behind  forwards 
and  either  above  or  below  the  canal,  as  the  operator  may 
prefer. 

I  cannot  close  these  remarks  upon  internal  urethrotomy 
without  expressing  the  opinion  that  the  tendency  of  the 
present  day  is  to  underrate  the  skill  and  experience  required 
for  its  performance,  to  undervalue  its  dangers  and  inconve- 
nience to  tlie  patient,  and  to  resort  to  it  with  unnecessary 
frecpiency.  It  may  not  require  such  skill  as  is  demanded 
for  tiie  extraction  of  cataract,  and  which  ought  to  delegate 
that  operation  exclusively  to  specialists,  but  it  requires  an 
amount  of  care,  skill,  and  experience  not  possessed  by  every 
practitioner  of  medicine  or  every  man  calling  himself  a  sur- 
'on.  I  will  quote  a  case  in  point : — 
Mr.  A.,  aged  38,  was  operated  on  by  Dr.  Z.,  a  surgeon  of  this  city,  at 


Civiale's 
urethrotome. 


.'  Otis,  op.  cit.  p.  37. 


RUPTURE.  309 

the  latter's  office  for  three  strictures,  situated  respectively  at  one  inch,  two 
incites,  and  four  inches  from  the  meatus.  Maisonneuve's  urethi-otome, 
with  the  blade  cutting  dowmoards  and  provided  with  a  guide,  was  em- 
])loyed.  The  first  and  second  strictures  were  cut  easily,  but  the  last  with 
difficulty  and  with  the  use  of  some  force.  Considerable  hemorrhage  fol- 
lowed immediately  upon  the  operation,  and,  on  the  following  day.  Dr.  Z. 
was  summoned  to  patient's  house.  He  had  had  a  chill,  was  almost  pulse- 
less, and  in  such  collapse  that  it  was  thought  he  would  die  that  night. 
The  scrotum  and  penis  were  much  swollen,  and  incisions  made  into  these 
parts  gave  issue  to  a  bloody  fluid  which  was  evidently  mostly  urine.  At 
the  end  of  a  week,  sloughing  began  and  progressed  until  the  anterior  surface 
of  the  scrotum  had  come  away  together  with  the  under  sui-face  of  the  penis 
from  the  base  of  the  fraenum  to  the  peno-scrotal  angle,  exposing  the  urethra 
to  this  extent,  its  upper  wall  alone  remaining.  The  patient  finally 
recovered,  and  Avas  relieved  of  his  hypospadias  in  one  of  our  hospitals  by 
means  of  several  plastic  operations.  In  this  case  it  is  probable  that  the 
steel  shaft  of  the  instrument  did  not  follow  the  guide,  and  was  thrust 
through  the  urethral  wall. 

This  operation  is  also  not  free  from  danger  to  life,  although  this  depends 
in  a  great  measure  upon  the  seat  of  its  performance.  Those  surgeons  who 
limit  it  to  the  first  two  or  three  inches  of  tiie  urethi'a  may  be  able  to  re- 
port a  large  number  of  cases  without  a  single  fatal  result,  but  if  this  limit 
be  exceeded,  deaths  will  often  follow  as  a  consequence,  even  when  great 
caution  has  been  used ;  and  instances  of  this  kind  are  every  little  while 
coming  to  our  knowledge  in  a  quiet  way.  I  have  myself  lost  two  patients 
from  septicaemia  following  internal  uretiirotomy  for  strictures  situated  about 
four  and  one  half  inches  from  the  meatus,  the  one  occurring  four  days  and 
the  other  fourteen  days  after  the  operation. 

The  minor  evils  liable  to  follow  the  operation,  as  urethral  fever,  hemor- 
rhage, incurvation  of  the  penis,  etc.,  are  by  no  means  inconsiderable,  and 
will  receive  attention  in  the  section  on  the  Consequences  of  Operations  on 
Stricture. 

In  view  of  the  above  considerations,  the  surgeon  may  well  avoid  internal 
urethrotomy,  unless  decidedly  called  for,  and  when  other  means  are  unavail- 
able. Knowing  what  I  do  of  the  operation,  if  I  had  a  marked  and  annoy- 
ing stricture  in  the  anterior  portion  of  the  urethra,  or  if  I  had  an  obstinate 
gleet  which  no  other  means  would  relieve,  or  if  I  were  the  subject  of  one 
of  those  tormenting  neuralgias  d('|)endent  u])on  stricture  that  we.  read  of\  I 
v.'ould  have  my  stricture  cut;  but  if  I  had  only  a  "  stricture  of  large  calibre" 
presenting  no  obstruction  to  the  urine  and  occasioning  no  inconvenience, 
no^argument  drawn  from  possible  ills  in  the  future  could  persuade  me  to  be 
subjected  to  tlie  knife,  and — what  a  surgeon  would  not  have  done  to  him- 
self he  lias  no  right  to  recommend  to  others  ! 

Rnpture Of  late  years,  the  rupture  of  stricture,  which  w'as  formerly 

advocated  by  Perreve,  has  become  quite  generally  known,  chiefly  through 
the  labors  of  Mr.  Holt,  of  the  Westminster  Hospital,  London. 

Mr.  Holt's  instrument,  a   modification  of  that  of  Perreve,  "  consists  of 


310 


STRICTURE    OP    THE    URETHRA. 


Fig.  97. 


two  grooved  blndes  fixed  in  a  divided  handle,  and  containing  between  them 
a  wire  welded  to  their  points,  and  on  this  wire  a  tube  (which,  when  in- 
troduced  between  the  blades   corresponds  to   the  natural  calibre  of  the 

ui'ethra)  is  quickly  passed,  and   thus  ruptures 
or  splits  the  obstruction.'" 

The  instrument,  as  originally  proposed  by 
Mr.  Holt,  possessed  certain  defects  which  T 
have  endeavored  to  remove.  It  was  evident 
to  others  as  well  as  myself,  that  the  expansive 
power  of  the  instrument  was  insufficient ;  that 
even  when  the  largest  tube  of  the  set  was  em- 
ployed, there  were  some  strictures  which  would 
merely  stretch  as  it  passed  without  being  rup- 
tured, and  which  would  afterwards  show  the 
marked  tendency  to  recontraction  which  always 
follows  rapid  dilatation.  The  remedy  for  this 
was  evident, — to  allow  wider  separation  of  the 
blades,  and  to  be  supplied  with  larger  tubes, 
one  of  which,  after  slitting  up  the  meatus, 
could  be  selected  corresponding  in  size,  not 
to  the  external  orifice  as  Mr.  Holt  advises, 
but  to  the  calibre  of  the  spongy  portion  of 
the  urethra. 

The  other  changes  which  I  have  introduced, 
consist  in  having  the  point  of  the  instrument 
at  a  right  angle  to  the  shaft,  following  Mr. 
Thompson's  curve,  with  a  view  of  facilitating 
its  introduction,  and  in  adding  a  filiform  attach- 
ment to  serve  as  a  guide  for  the  shaft  wliich  is 
ecjual  in  calibre  to  No.  11  (three  and  two-thirds 
millimetres  in  diameter).  As  previously  stated, 
the  bougie  attachments  are  also  made  to  fit 
other  urethral  instruments  employed  for  inci- 
sion, etc.,  so  that  the  choice  of  the  operation 
is  still  open  after  tlie  guide  has  passed  the 
obstruction.  Tlie  instrument  thus  modified  is 
represented  in  Fig.  97.  I  do  not  think  any- 
thing is  gained  by  having  the  central  Avire 
hollow,  as  the  capacity  of  the  tube  thus  formed 
is  too  small  to  allow  of  the  passage  of  the  urine, 
and  the  instrument  ought  not  to  be  in  the  hands 
of  any  one  who  has  not  other  means  of  judging 
whether  he  has  entered  the  bladder  or  not. 
The  instrument  may,  of  course,  be  used  with- 
out the  bougie  attachment,  its  screw-point  be- 
ing protected  with  a  cap  provided  for  the  pur- 
Author's  modification  of  Mr.  ^  *■    *■  *• 

Holt's  iustriimeut.  pOSe 


RUPTURE. 


311 


In  using  this  instrument  the  shaft  should  Fig-  98. 

be  passed  fairly  through  the  stricture,  so 
that  the  latter  may  feel  the  full  force  of 
the  rupturing  tube.  The  point  of  the 
tube  selected  is  then  to  be  placed  upon 
the  wire  between  the  blades,  and  to  be 
thrust  down  as  rapidly  as  possible  to  the 
end,  in  order  to  insure  rupture  and  not 
mere  dilatation  of  the  contraction.  Before 
withdrawing  the  instrument,  it  is  to  be 
rotated  so  as  to  separate  still  further  the 
sides  of  the  rent. 

Mr.  Holt  believes  that  by  this  method 
the  mucous  membrane  of  the  urethra  "  is 
not  torn  but  simply  dilated,  and  the  sub- 
mucous deposit,  the  cause  of  the  obstruc- 
tion, is  alo)ie  split,  hence  the  trifling  hem- 
orrhage and  the  impossibility  of  infiltration 
of  urine."  I  entertain  doubts  of  the  cor- 
rectness of  this  view,  and  the  lining  mem- 
brane of  the  canal  has  certainly  been  found 
to  be  lacerated  in  several  instances  of  post- 
mortem examination  ;  but,  however  that 
may  be,  tliis  is  one  of  our  best  means  for 
the  treatment  of  certain  strictures. 

Voillemier's  rupture  instrument  may  also 
be  recommended.  I  have  had  the  tubes 
made  larger  than  in  the  original  instru- 
ment ;  my  largest  tube  equals  No.  29,  and 
the  smallest  No.  25  of  the  French  scale. 

This  instrument  appears  to  possess  one 
decided  advantage  over  Mr.  Holt's.  The 
tube,  instead  of  sliding  upon  a  central  wire 
betwcfui  the  blades,  is  jorovided  witli  grooves 
on  either  side  for  the  blades  to  play  in, 
and  thus,  as  shown  in  the  cut,  a  trans- 
verse section  of  the  instrument  is  circular 
instead  of  oval,  and  the  rupturing  force  is 
spent  ecpiiilly  upon  the  whole  circumference 
of  the  canal. 
»  As  previously  stated,  rupture  is  ada])ted 

,       .    •    .  ,.     ,  ,  ,  ■  .  VoiUi^iiiier's       rupture- instniment. 

to  such  strurtures  ot  the  sub-pubic  portion      „  „,  shafi  of   the    iastn.mnut,  split 
of  the  canal,  as  are  too  irritable  to  admit  of     throughout  the  straight  poitiou.  f  o, 

,.,    ^      .  1  .    1  1  M  •  i  flliforni  bougie,     e,  cap  to  he  applied 

dilatation  or  which  exhibit  a  strong  ten-     iu  case  tho  bougie  i«  not  usod.    a,  rup- 
dency  to   recontraction.     It  may  also   be     tming  miio.     n,  transverHo  soction  of 

,  ,  .  ,.  .  ^      the  K«iiie,  showioi,'  tho  u'loovos  for  the 

used  to  advantage  in  cases  ot   retention  of     receptiou  of  the  blades  of  the  shaft. 


312  STRICTURE    OP    THE    URETHRA. 

urine  dependent  upon  strictures  in  this  situation,  when  fortunately  an  in- 
strument, either  preceded  or  not  by  a  guide,  can  be  passed  through  the 
obstruction. 

Caustics Caustics  in  the  treatment  of  stricture  have  been  superseded 

to  such  an  extent  by  other  and  more  vahiable  means,  that  they  have  at 
present  but  few  advocates,  and  I  would  fully  endorse  the  following  opinion 
of  them  expressed  by  Sir  Henry  Thompson  :  "  I  consider  the  application 
of  nitrate  of  silver  or  of  caustic  potash  to  a  permeable  stricture  to  be  un- 
necessary as  a  means  of  cure,  since  other  and  better  modes  of  treatment 
for  such  contractions  exist;  and  that '  impermeability,'  so  called,  is  a  con- 
dition always  to  be  overcome  by  the  careful  use  of  simple  instruments,  and 
not  to  be  attacked  by  any  caustic  or  escharotic  agents  whatever." 

ExTEiiN\A.L  Perineal  Urethrotomy. — Tliis  operation  may  be  re- 
quired or  deemed  advisable  under  several  circumstances,  which  may  be 
stated  in  a  few  words. 

1.  In  cases  of  impassable  or  tight  stricture,  complicated  by  retention  or 
infiltration  of  urine  or  by  abscess,  immediate  recourse  to  external  perineal 
urethrotomy  is  often  urgently  demanded,  and  offers  the  best  if  not  the  only 
chance  for  the  preservation  of  the  life  of  the  patient. 

2.  Under  less  pressing  circumstances,  the  same  operation  may  be  re- 
quired when  repeated  attempts  have  failed  to  pass  the  obstruction,  when  the 
stricture  is  extensive  and  of  traumatic  origin,  or  when  numerous  fistulous 
passages  exist. 

Such  instances  are,  however,  but  few  in  comparison  with  the  whole 
number  of  strictures  met  with,  and  the  employment  of  external  perineal 
urethrotomy  as  a  general  method  of  treatment,  recommended  by  the  late 
Mr.  Syme,  cannot  be  considered  justifiable.  Great  irritability  and  resili- 
ence of  the  contraction  were  formerly  regarded  as  indications  for  its  use, 
but,  in  such  cases,  it  has  been  supplanted  by  the  improved  methods  of  in- 
ternal urethrotomy  and  rupture,  and  these  will  also  be  found  sufficient  in 
some  instiinces  of  retention,  in  which  perineal  section  was  formerly  re- 
sorted to. 

At  the  time  of  performing  this  operation,  the  stricture  may  be  found  to 
present  either  one  of  three  degrees  of  contraction. 

1.  It  may  be  sufficiently  patent  to  enable  us  to  pass  a  grooved  sound, 
which  will  serve  as  a  guide  to  the  knife  introduced  through  the  perinanum 
in  its  division  of  the  obstruction.  We  then  perform  what  is  often  called 
"  Syme's  operation,"  or  "  external  perineal  urethrotomy  with  a  guide." 

2.  Failing  in  our  attempts  to  pass  the  stricture  by  any  instrument  in- 
serted through  the  natural  channel,  we  may  still  be  able  to  accomplish  the 
same,  after  o]»ening  the  urethra  in  front  of  the  obstruction,  and  thus  still 
avail  ourselves  of  a  guide  passed  from  the  perineal  incision  through  the 
contraction.  This  method,  although  by  no  means  new,  has  been  perfected 
by  Mr.  C.  G.  Wheelhouse,  of  Leeds,  and  is  called  by  P^nglish  surgeons 
"  Wheelhouse's  0|)eration." 

3.  Finally,  neither  of  the  above  attempts  having  succeeded,  the  only 
recourse  left  is  to  open  the  urethra  posterior  to  the  stricture,  which  possi- 
bly may  then  be  passed  from  behind  forwards ;  or,  in  other  instances,  the 


EXTERNAL    PERINEAL    URETHROTOMY. 


313 


Fig.  99. 


normal  channel  lias  become  so  obliterated  that  it  cannot  be  traced,  and  a 
new  and  artificial  channel  must  be  formed.     ("  Cock's  operation.") 

Whichever  of  these  methods  may  be  called  for,  it  is  highly  desirable, 
unless  the  urgency  of  the  case  forbids,  that  the  patient  should  be  prepared 
for  the  operation  by  a  period  of  rest,  during  which  he  should  be  confined 
to  the  house,  and,  for  the  most  part,  to  the  horizontal  posture,  his  secre- 
tions be  regulated,  and  his  system  placed  in  as  favorable  a  condition  as 
possible.  The  perina^um  should  be  shaved,  and  the 
rectum  evacuated  by  an  enema.  At  the  time  of  the 
operation,  the  patient  having  been  brought  under 
the  influence  of  ether,  he  is  placed  upon  the  edge  of 
a  table,  f\icing  a  good  light,  in  the  ])Osition  for  litho- 
tomy, with  the  hands  bound  to  tlie  feet  by  bandages, 
or  by  Pritchard's  anklets,  and  an  assistant  support- 
ing each  knee. 

AVhen  Syme's  operation  is  practicable,  the  staff 
bearing  the  name  of  this  surgeon  (Fig.  99)  is  intro- 
duced through  the  stricture,  or,  if  this  be  found 
impracticable,  a  sound  channelled  on  its  convexity 
and  tunnelled  at  its  extremity,  as  represented 
in  Fig.  80,  should  be  passed  down  to  the  ante- 
rior face  of  the  contraction,  threaded  if  possible 
upon  a  fine  whalebone  bougie,  wliich  it  may  have 
been  possible  to  introduce  into  the  bladder,  and 
which  will  serve  as  a  guide  to  the  sound  after  the 
incision  in  the  perinajum  has  been  made.  The  sound 
should  now  be  entrusted  to  the  assistant  on  the  pa- 
tient's left,  who  also  elevates  tlie  scrotum  out  of  the 
way  of  the  operator.  The  staff  is  to  be  held  accu- 
rately in  the  median  line  and  its  convexity  made 
somewhat  prominent  in  the  perinajum.  The  sur- 
geon, sitting  upon  a  stool  in  front  of  the  patient, 
enters  his  knife  into  the  centre  of  the  perinreum  and 
makes  an  incision  an  inch  and  a  half  or  two  inches 
long,  exactly  in  tlui  median  line,  cutting  down  upon 
the  groove  of  the  staff';  using  this  as  a  guide, 
the  stricture  beyond  can  be  readily  and  freely  di- 
vided on  its  lower  aspect.  It  is  generally  recom- 
mend(;d  in  books  to  make  this  division  by  successive 
strokes  with  tiie  knife  from  behind  forwards,  as  re- 
l)wesented  in  Fig.  100,  lest,  if  made  in  the  opj)Osite 
direction,  the  knife,  after  severing  the  stricture  and 
ceasing  to  meet  with  resistance  from  the  induration, 
unnecessarily  wound  the  dee})er  tissues.  As  a  mat- 
ter of  fact,  however,  I  belie\e  this  rule  is  not  ob- 
served ;  at  least  I  have  never  seen  it  carried  out,  and  have  found  others 
as  well  as  myself  accustomed  to  make  the  incisions  in  the  opposite  direc- 
tion, i.e.,  from  before  backwards. 


Syme's  staff. 


314  STRICTURE    OF    THE    URETHRA. 

A  grooved  director  is  now  to  be  introduced  into  the  bladder  through  the 
perineal  incision  ;  the  stafFis  withdrawn  and  a  full-sized  sound  or  catheter 
inserted  from  the  urethra  and,  guided  by  the  director,  into  the  bladder,  to 
ascertain  if  the  strictured  portion  of  the  urethra  has  been  completely  cut. 


Fig.  loa 


(After  Thompson.) 


When  the  stricture  is  found  impassable  and  we  cannot  therefore  have 
the  assistance  of  a  staff  as  in  Syme's  operation,  a  full-sized  channelled 
sound  is  to  be  introduced  as  far  as  the  anterior  face  of  the  obstruction  and 
an  incision  to  be  made  upon  it  from  the  perinajum,  as  in  the  previous  ope- 
ration. An  effort  should  then  be  made  to  pass  an  instrument  through  the 
stricture  by  way  of  tlie  perineal  opening.  For  this  purpose,  the  edges  of 
the  incision  should  be  held  apart  by  the  fingers  of  assistants,  or  by  means 
of  hooks,  or,  better  still,  as  proposed  by  Mr.  Avery,  a  ligature  may  be 
passed  through  the  urethral  mucous  membrane  on  either  side,  in  order  to 
afford  a  clearer  field  of  view,  and  indicate  the  ])osition  of  the  channel ;  and 
the  blood  should  be  removed  by  constant  si)onging.  The  most  desirable 
instrument  to  insert  is  a  grooved  director ;  if  this  cannot  be  passed,  a  fine 
flexible  bougie,  or  even  a  bristle  may  be  tried.  Considerable  time,  pa- 
tience, and  perseverance  are  required  in  this  part  of  the  operation,  which 
often  occupies  from  fifteen  to  thirty  minutes,  but  in  most  cases,  one  of  the 
above  instruments  may  eventually  be  passed  and  employed  as  a  guide  for 
the  completion  of  the  operation. 

Mr.  Whe(^lhouse,'  of  Tweeds,  lias  further  methodized  the  steps  of  this  ope- 
ration and  introduced  some  new  instruments  for  the  purpose,  which  are 
highly  spoken  of  by  English  surgeons. 

1  British  jSI.  J.,  London,  June  24,  1876. 


EXTERNAL    PERINEAL    URETHROTOMY. 


315 


The  following  are  the  specual  instruments  recjuired  in  Wheelhouse's  ope- 
ration. 

A  staff,  grooved  to  within  a  half-incli  of  its  extremity,  which  terminates 
in  a  rounded  button-like  end  (Fig.  101)  ;  two  pair  of  straight  forceps  nibbed 


Fig.  101. 


Grooved  staff  with  button  like  ead. 


at  their  points ;  a  grooved  probe-pointed  director;  Teale's  probe-gorget 
(Fig.  102)  ;  a  short  silver  catheter  (No.  10  or  11)  with  elastic  tube  at- 
tached. 

Fis.  102. 


Fig.  103. 


Teale's  probe-gorget. 

The  patient  liaving  been  placed  in  tlie  lithotomy  position,  the  staff  is 
introduced,  with  the  groove  looking  towards  the  Hoor  of  the  urethra,  and 
brouglit  gently  in  contact  witli 
the  stricture.  The  perinaium 
is  then  divided  by  an  incision 
extending  fi-om  opposite  tlie 
point  of  reflection  of  the  super- 
ficial [)erineal  fascia  to  tlie  ante- 
rior margin  of  the  sphincter  ani 
muscle.  On  reaching  the  nre- 
tlira,  tiiat  canal  is  to  be  opened 
in  tlie  groove  of  the  staff,  tlius 
securing  at  least  a  quarter  of  an 
inch  of  healthy  undivided  tissue 
anterior  to  the  stricture.  The 
edges  of  the  incision  being  held 
apart  by  the  nibbed  forceps,  tlie 
staff  is  gently  withdrawn  and 
turned  around  so  that  the  bot- 
tom may  hook  into  tlie  anterior  angle  of  the  incision.  The  urethra  mav 
thus  i)e  stretched  open  at  three  points  and  the  operator  may  look  into  it 
directly  in  front  of  the  stri(;turc. 

The  prolie-pointed  director  is  then  passed  into    the  urethra  through  the 
cut,  and,  even  if  the  opening  of  the  stricture  cannot  be  seen,  it  usually 


Wheelhouse's  operation  of  opening  the  urethra. 


316  STRICTURE    OF    THE    URETHRA. 

succeeds  in  finding  the  way.  The  director,  having  reached  the  bladder,  is 
held  with  its  groove  downwards  and  along  it  the  stricture  is  thoroughly- 
divided.  In  order  to  insure  tlie  easy  introduction  of  the  catheter,  the  probe- 
gorget  is  passed  into  the  bladder  on  the  groove  in  the  director,  forming  a 
metallic  floor  for  the  catheter  to  pass  over.  The  siiort  catheter,  with  the 
elastic  tube  attached,  is  then  easily  introduced  from  the  meatus  into  the 
bladder  ;  the  gorget  is  withdrawn  and  the  catheter  fastened  in  and  allowed 
to  remain  for  three  or  four  days,  the  urine  being  conveyed  to  a  convenient 
distance  by  the  elastic  tube.  On  the  fourth  day  the  catheter  is  removed 
and  is  "subsequently  passed  every  second  or  third  day,  until  the  wound  in 
the  perina^um  is  healed. 

There  still  remain  cases  in  which  both  of  the  above-mentioned  opera- 
tions are  impracticable,  since  no  guide  can  be  made  to  pass  the  stricture, 
introduced  either  from  the  meatus  or  the  perineal  opening.  In  such 
instances  we  may  occasionally  take  advantage  of  a  fistulous  opening  in 
the  perinteum,  through  which  we  can,  perhaps,  insinuate  a  fine,  olive- 
tipped,  whalebone  bougie,  and  upon  this  slide  a  fine  silver  tube  which 
will  relieve  any  urgent  symptoms  of  retention  present,  and  also  greatly 
assist  our  efTorts  to  trace  out  the  natural  channel.  These  fistula),  however, 
would  better  be  let  alone,  unless  we  can  first  be  satisfied  that  the  probe  or 
bougie  traverses  their  whole  course  and  enters  the  bladder.  Prof.  Dittel, 
of  Vienna,  has,  however,  reported  a  few  cases  in  which  perineal  fistulae 
were  so  fortunately  situated  that  a  probe  could  be  passed  into  the  urethra 
behind  the  stricture  and  thence  forward  through  it. 

Only  two  further  plans  remain  for  adoption :  either  to  carefully  cut  into 
the  indurated  mass  of  the  stricture  by  successive  strokes  of  the  knife,  in 
hopes  of  discovering  the  natural  channel,  or  to  open  tlie  dilated  urethra 
behind  the  obstruction  and  then  endeavor  to  pass  a  probe  through  it  from 
behind  forwards.  During  the  latter  operation,  after  each  stroke  of  the 
knife,  the  parts  should  be  carefully  examined  by  the  finger,  and  if  a 
fluctuating  })oint  can  be  felt,  it  is  probably  the  dilated  urethra,  and  should 
be  opened.  In  spite  of  all  our  eftbrts,  it  may  be  impossible  to  trace  the 
contracted  and  thread-like  remains  of  the  normal  passage,  and  we  must 
content  ourselves  with  opening  the  urethra  back  of  the  obstruction  and 
establishing  an  artificial  channel  with  the  penile  ])ortion  of  the  canal.  This 
may  be  found  eventually  to  supply  the  place  of  the  original  passage  in 
quite  a  satisfactory  manner. 

In  performing  the  operations  above  described,  there  is  one  anatomical 
point  M'hich  should  always  be  borne  in  mind,  and  that  is  the  position  of 
the  opening  in  the  triangtdar  ligament  through  which  the  urethra  passes. 
This  is  situated  at  three-fourths  of  an  inch,  or  about  a  finger's  breadth, 
below  the  arch  of  the  pubes.  It  is  often  sought  for  too  far  backwards  and 
too  near  the  anus. 

Cock's  Operation. — Mr.  Cock,  of  Guy's  Hospital,  advocates  for  the  relief 
of  retention  of  urine,  the  opening  of  the  urethra  behind  the  stricture  at  the 
apex  of  the  prostate,  in  the  following  manner:  "Tiie  patient  being  in  the 
lithotomy  position,  tlie  left  forefinger  of  the  operator  is  placed  in  the  rectum. 


cock's  operatiox. 


317 


with  its  tip  at  the  apex  of  the  prostate,  the  relations  of  which  should  be 
carefully  ascertained.  A  double-edged  knife  is  then  plunged  steadily,  but 
boldly,  into  the  median  line  of  the  perinfeum,  and  carried  in  a  direction 
towards  the  tip  of  the  forefinger  which  lies  in  the  rectum,  while,  at  the 
same  time,  by  an  upward  and  downward  movement,  the  incision  is  enlarged 
in  the  median  line  to  any  extent  that  is  considered  desirable.  The  lower 
extremity  of  the  wound  reaches  to  within  about  half  an  inch  of  the  anus. 

Fis.  104. 


Tapping  the  urethra  in  the  perinaeum.     (Bryuiit.) 

The  knife  is  pressed  steadily  onwards  towards  the  apex  of  the  prostate, 
until  its  point  can  be  felt  in  close  proximity  to  the  tip  of  the  left  forefinger, 
and  is  then  made  to  pierce  the  urethra  by  advancing  it  obliquely  either  to 
the  right  or  left.  The  finger  is  still  kept  in  the  rectum,  while  the  knife 
is  withdrawn,  and  a  probe-pointed  director  introduced  through  the  wound 
into  the  urethra  and  passed  into  the  bladder.  The  finger  is  then  with- 
drawn and  the  director  held  in  the  left  hand,  while  a  canula  or  female 
catheter  is  slid  along  its  groove  into  the  bladder,  where  it  is  retained  for 
a  few  days.'" 

Furneaux  Jordan,  of  Birmingham,  Eng.,  recommends  opening  the  uri- 
nary track  from  the  rectum  and  passing  a  soft  instrument  forward  through 
the  stricture  and  out  at  the  external  meatus,  the  other  end  being  carried 
into  the  bladder.  He  states  that  in  some  instances  he  has  found  the  dis- 
tended bladder  itself  coming  down  as  far  as  the  anal  sphincter,  in  which 
case  this  viscus  may  be  incised  with  a  bistoury,  followed  by  the  introduc- 
tion of  the  finger  and  the  passage  of  an  instrument  forwards  from  the  in- 
ternal meatus  to  the  external. 

'Retrograde  catheterism  has  also  been  performed  by  taking  advantage  of 
a  supra-pubic  opening  into  the  bladder,  through  which  an  instrument  is 
passed  into  this  viscus  and  thence  forward  through  the  urethra  until  if  is 
arrested  by  the  stricture.  Brainard,  of  Chicago,  in  1849,  punctured  the 
bladder  above  the  pubes  for  the  express  puri)0se  of  such  a  procedure,  and 
has  been  followed  by  Volkmann  and  others. 

'  Quoted  from  Ashhurst's  Surgery,  2d  ed.,  p.  930. 


318  STRICTURE    OF    THE    URETHRA. 

The  after-treatment  of  either  of  the  above  operations  of  external  ure- 
throtomy is  simple.  The  patient  should  be  put  to  bed  with  the  thighs 
elevated  and  the  bedclothes  supi)orted  by  a  cradle.  Pain  may  be  relieved 
by  suppositories  of  opium,  and  one  should  be  introduced  within  the  anus 
before  the  patient  leaves  the  table.  Subsequent  hemorrhage  sometimes 
occurs  which  it  is  difficult  to  arrest  by  ligature,  since  the  thread  does  not 
retain  a  firm  hold  upon  the  gristly  tissue  of  the  stricture  ;  it  may,  however, 
be  effectually  controlled  by  inserting  a  piece  of  compressed  sponge  between 
the  edges  of  the  wound,  or  firmly  plugging  it  with  lint,  and  bandaging  the 
thighs  together. 

It  was  formerly  the  custom  to  tie  a  catheter  in  the  bladder  for  twenty- 
four  to  forty-eight  hours,  but  it  is  now  believed,  especially  by  Prof.  Van 
Buren  and  others  of  our  best  American  authorities,  that  this  practice  is 
not  only  unnecessary,  but  that  it  tends  to  favor  urethral  fever,  and  other 
unpleasant  symptoms.  If  a  catheter  be  dispensed  with,  the  urine  escapes 
through  the  incision  for  a  few  hours,  but  is  found  to  pass  mainly  through 
the  natural  channel  by  the  following  day,  when  the  perineal  opening  is 
closed  by  the  swelling  of  its  edges. 

Very  disastrous  results  have  been  known  to  follow  the  prolonged  reten- 
tion of  a  metallic  catheter  after  this  oi)eration,  the  chief  of  which  is  ulcer- 
ation of  the  mucous  membrane  and  subjacent  tissues  in  consequence  of 
pressure  of  the  instrument.  This  most  frequently  occurs  at  two  points  : 
one,  that  portion  of  the  vesicle  walls,  which  comes  in  contact  w^ith  the 
extremity  of  the  catheter  ;  the  other,  the  lower  surface  of  the  urethra  just 
in  advance  of  the  scrotum,  at  the  commencement  of  the  sub-pubic  curve, 
where  the  penis  is  upheld  by  the  suspensory  ligament,  and  where  any 
straight  instrument,  like  the  shaft  of  a  catheter,  necessarily  presses  upon 
the  inferior  wall  of  the  canal.  Hence  if  any  catheter  is  to  be  retained,  it 
should  be  a  flexible  one. 

It  might  be  inferred  from  the  opinion  expressed  on  a  previous  page  as  to 
the  permanence  of  the  cure  after  free  division  in  internal  urethrotomy,  that 
so  free  a  division  as  is  performed  in  extenial  urethrotomy  would  require  no 
further  use  of  instruments  after  the  healing  of  the  wound  and  the  appa- 
rent restoration  of  the  urethra  to  its  normal  calibre.  Experience,  however, 
shows  the  contrary  and  demonstrates  the  necessity  of  tlie  use  of  sounds 
at  intervals,  for  an  indefinite  period  varying  in  different  cases,  or  other- 
wise a  relapse  is  almost  sure  to  occur.  Wherein  the  difference,  if  any,  lies 
between  external  and  thorough  internal  urethrotomy,  I  am  unable  to  explain. 
AV'hen  perineal  section  is  followed  by  a  fatal  termination,  it  is  in  most 
cases  due  to  pyaemia ;  sometimes  to  urethral  fever,  attended  or  not  with 
suppression  of  urine ;  and  at  other  times  to  hospital  gangrene,  erysipelas, 
or  urinary  infiltration. 

Consequences  of  Operations  upon  Strictures — Hemorrhage  is 
not  unfrequently  an  unpleasant  accident  following  operations  upon  stric- 
tures, especially  those  of  rupture  and  internal  urethrotomy.  It  is  not  so 
much  to  be  feared  at  the  time  of  the  operation  as  at  some  subsequent 
period,  more  particularly  after  the  passage  of  urine  or  on  the  occurrence 


CONSEQUENCES    OP    OPERATIONS. 


319 


of  an  erection  at  ni^^ht.  Tt  shows  itself  usually  within  three  or  four  days 
after  the  operation,  but  the  patient,  especially  after  internal  urethrotomy, 
is  not  free  from  this  danger  for  -ten  days  or  a  fortnight — instances  of  its 
occurrence  at  this  late  period  being  now  and  then  met  with.  Knowing 
the  site  of  the  stricture  operated  upon,  the  surgeon  will  be  able  to  deter- 
mine very  nearly  the  situation  of  the  bleeding  point ;  moreover,  if  the 
latter  be  in  the  penile  portion  of  the  canal,  the  blood  will  flow  continu- 
ously from  the  meatus,  or,  if  in  the  portion  of  tlie  canal  posterior  to  the 
bulb,  the  blood  may  flow  backwards  and  even  distend  the  bladder  with 
clots. 

The  liability  to  tliis  accident  emphasizes  the  necessity  of  keeping  a 
patient  quiet,  and  preferably  in  the  horizontal  posture  for  some  days  after 
the  operation,  and  also  of  his  having  a  faithful  attendant.  Should  hemor- 
rhage occur,  it  may  often  be  conti'olled  by  the  application  of  ice  to  the 
penis  and  tlie  perineum.  If  obstinate,  and  the  bleeding  point  be  situated 
in  the  pendulous  portion  of  the  canal,  a  moderate-sized  catheter  should  be 
introduced  and  pressure  be  exercised  by  a  bandage  encircling  the  penis. 
"When  tlie  source  of  the  bleeding  is  more  deeply  seated,  pressure  may  be 
most  conveniently  exercised  lupon  the  perinttum  in  the  following  manner  : 
Place  upon  the  perinajum  a  pad  of  sufficient  thickness ;  tie  a  bandage 
firmly  round  the  waist ;  finally,  pass  an  elastic  bandage  by  a  number  of 
turns  from  behind  forwards  and  from  before 
backwards,  between  tlie  buttocks  and  over  the 
pad,  from  the  waist-bandage  behind  to  the  same 
in  front. 

A  less  convenient  way  is  to  use  a  crutch,  its 
lower  extremity  resting  against  tlie  foot-board 
of  the  bed,  and  its  upper  against  the  perinieum 
of  the  patient.  Dr.  Otis  has  also  invented  a 
tourniquet  for  the  purpose  (Fig.  105),  and 
recommends  that  it  sliould  be  applied  loosely 
directly  after  the  operation,  so  as  to  be  tight- 
ened in  a  moment  if  necessary.' 

Among  the  haemostatics  which  may  be  given 
by  the  mouth  in  severe  cases,  ipecac  and  ergot 
are  especially  worthy  of  mention.     Should  the 

bhidder  become  distended  with  blood-clots,  it  may  be  desirable  to  wash  out 
this  viscus  with  warm  water  injected  tlirougii  a  catheter. 

Curvature  of  the  penis  is  met  with  in  many  cases  following  internal 
urethrotomy  of  the  penile  urethra.  It  may  not  be  seen  when  the  organ  is 
at^rest,  but  in  a  state  of  erection,  the  virile  member  becomes  bent  usually 
to  one  side  or  the  otlier,  or  in  some  cases  eitlier  upwards  or  downwards, 
and  it  may  be  to  such  an  extent  as  to  interfere  with  or  entirely  prevent 
sexual  intercourse.  The  extreme  advocates  of  internal  urethrotomy  are 
inclined   to   make  light  of  tliis  accident,  which   is,  however,  for  obvious 


Fig.  105. 


Otis'    iierineal  touraiquet. 


•  The  multiplicity  of  tlie  means  advised  to  arrest  liemorrhage  is  suggestive  of 
the  liability  of  its  occurrence.     (See  Otis,  op.  cit.  p.  280.) 


320  STRICTURE    OF    THE    URETHRA. 

reason.*,  very  annoying  and  distressing  to  the  patient.  It  may  disappear 
spontaneously  within  a  few  weeks,  but  in  some  cases  it  continues  for  months 
and  even  for  a  year  or  h)nger.  In  the  treatment  of  this  accident,  we  have 
thought  that  some  benefit  was  derived  from  supplying  the  patient  with  a 
straight  sound  and  directing  him  to  introduce  it  morning  and  night,  and 
then  to  practise  a  certain  amount  of  friction  and  of  massage  over  it  at  the 
point  of  curvature.  Dr.  Otis  states  that  in  one  instance  of  this  deformity, 
which  had  lasted  a  year,  he  effected  a  cure. by  dividing  the  superior  wall 
of  the  urethra  in  a  diagonal  line,  using  for  the  [)urpose  a  modification  of  his 
dilating  urethrotome.^ 

Urethral  fever  is  a  still  more  formidable  sequence  of  operations  upon  the 
urethra,  any  one  of  which  may  occasion  it.  The  exciting  cause  may  be 
simple  over-distension  of  the  urethra  by  a  larger  bougie  than  has  before 
been  used ;  abrasions  or  laceration  of  its  walls  by  rough  handling  of  the 
instrument ;  the  application  of  caustic  ;  or  the  employment  of  the  knife  in 
internal  or  external  incisions.  The  patient  is  suddenly  seized  with  a  chill, 
headache,  vomiting,  acceleration  of  the  pulse,  and  in  severe  cases  with 
great  prostration  and  delirium.  These  symptoms  are  most  likely  to  ensue 
upon  the  first  act  of  micturition  succeeding  the  introduction  of  a  sound, 
or  an  operation  of  rupture  or  urethrotomy;  in  other  words,  they  follow, 
and  a[)pear  to  depend  upon  contact  of  the  urine  with  an  abraded  surface, 
through  which  urea  or  i)utrid  elements  find  entrance  into  the  general 
circulation  ;  in  other  instances  they  are  apparently  due  to  the  shock  im- 
pressed upon  the  nervous  system  alone.  This  combination  of  symptoms, 
which  is  known  as  "  urethral  fever,"  is  but  one  form  of  surgical  fever,  in 
the  etiology  of  which  the  absorption  of  septic  matter  from  the  neighbor-* 
hood  of"  wounds  plays  so  important  a  part. 

In  most  cases,  urethral  fever  terminates  in  resolution,  either  with  or 
without  treatment,  in  the  course  of  a  few  hours;  but  especially  in  persons 
affected  with  renal  disease,  and  in  some  instances,  without  a))parent  cause, 
a  typhoid  condition  with  delirium  sets  in,  abscesses  may  form  in  different 
parts  of  the  body,  and  speedy  death  ensue.  Complete  suppression  of  the 
urine  is  an  occasional  symptom,  and  is  to  be  regarded  as  of  very  serious 
import. 

In  order  to  conduct  the  treatment  of  stricture  with  safety,  the  general 
system  should  be  in  as  favorable  a  condition  as  possible;  the  digestive 
organs  in  good  order  ;  and  the  patient  should  avoid  excess  both  in  diet 
and  exercise.  It  is  important  also  to  abstain  from  any  operative  procedure 
during  the  persistence  of  raw  and  damp  weather,  or  when  the  patient  is 
fatigued  or  mentally  depressed.  If  rigoi's  occur  after  the  operation,  they 
should  be  met  by  the  external  application  of  heat  and  rubefacients,  as 
bottles  of  hot  water  to  the  extremities,  sinapisms  to  the  spine  and  abdo- 
men, hot  blankets,  etc,  ;  and  internally  by  stimulants,  quinine,  and  opiates. 
A  full  dose  of  the  latter  shoidd  be  administered  at  the  outset,  and  a  smaller 
q^uantity  be  repeated  every  few  hours,  so  as  to  maintain  a  steady  narcotic 

'  Op,  cit.  p,  290. 


TREATMENT    OF    RETENTION    OF    URINE.  321 

action  and  lull  the  irritability  of"  tlie  nervous  system.  The  reaction  which 
generally  follows  should  not  be  treated  by  active  depletion  ;  a  tendency  to 
general  depression  soon  supervenes,  in  which  the  vital  powers  must  be 
supported  by  stimulants  and  nourishment  until  nature  shall  have  elimi- 
nated the  toxic  materials  which  have  found  entrance  into  the  system.  The 
value  of  aconite,  administered  in  minute  doses  after  an  operation,  as  a 
propliylactic,  has  already  been  alluded  to. 

Treatment  of  Retention  of  Urine. 

Retention  of  urine  chiefly  occurs  either  during  the  acute  stage  of  gonor- 
rhoea, when  it  is  due  to  inflanmiation  and  spasm  ;  or  at  some  period  of 
organic  stricture,  when,  in  addition  to  the  causes  just  mentioned,  perma- 
nent contraction  of  the  canal  plays  a  more  or  less  important  part  in  its 
production.  It  is  less  frequent  in  the  former  cases  than  in  the  latter,  and 
{)resents  less  difficulty  in  the  wj^y  of  treatment.  Remedial  measures  must 
vary  somewhat  with  the  condition  of  the  patient,  and  be  determined  by 
the  judgment  of  the  surgeon. 

Relief  may  often  be  obtained  by  immersing  the  patient  in  a  hot  bath, 
the  temperature  of  which  sh.ould  be  raised  to  the  neighborhood  of  102°  F. 
and  this  will  probably  require  the  addition  of  hot  water  after  his  entrance, 
since  the  bath  cannot  at  first  be  borne  at  so  great  a  degree  of  heat,  and  is 
moreover  cooled  by  contact  with  the  body.  It  is  even  desirable  that  a 
state  of  syncope  should  be  induced,  which  will  greatly  favor  the  reduction 
of  spasmodic  action.  In  most  cases,  the  patient  will  pass  his  urine  during 
immersion;  otherwise,  he  should  be  rendered  insensible  by  ether,  and  a 
medium-sized  catheter,  as,  for  instance.  No  15  (French),  should  be  well 
warmed  and  oiled,  and  an  attempt  be  made  to  introduce  it,  following  the 
rules  already  laid  down,  adhering  closely  to  the  upper  surface  of  the 
urethra,  stopping  for  a  moment  whenever  obstruction  is  met  with,  and 
endeavoring  to  overcome  it  by  gentle  but  continuous  [)ressure.  If  these 
measures  do  not  succeed,  and  the  symptoms  are  at  all  urgent,  we  have  a 
ready  method  of  speedy  relief  in  puncture  of  the  bladder  above  the  pubes 
by  meatis  of  an  aspirator — a  procedure  which  may  be  said  to  be  devoid  of 
danger,  and  which  has  I'emoved  from  simple  retention  of  urine  nearly  all 
of  its  former  terrors. 

But  retention  of  urine  most  frequently  occurs  in  jiaticnts  with  organic 
stricture,  who,  after  exposure  to  cold,  or  after  excessive  indidgence  in  food 
and  stimulants,  suddenly  find  themselves  unable  to  pass  their  urine.  Tiie 
bladder  beeon)es  distended,  and  before  the  aid  of  the  surgeon  is  sought 
other  complications  may  have  taken  place,  as  rupture  of  the  urethra 
behind  the  stricture,  infiltration  of  urine,  the  formation  of  an  abscess,  etc. 
As  these  conditions  vary  in  different  cases,  so  must  the  re<iuirements  of 
each  be  subject  to  the  judgment  of  the  surgeon. 

A  careful  inspection  should  be  made  of  the  periiueum,  since  the  reten- 
tion may  be  due  solely  to  the  presence  of  an  abscess  or  urinary  infiltra- 
tion, the  evacuation  of  which  will  aflfbrd  relief.  When  such  collections  form 
21 


322 


STRICTURE    OF    THE    URETHRA. 


Fig.  106. 


])Ostt'rior  to  tlie  triansnlar  lijiameiit,  tl)e  external  symptoms  may  be  very 
obscure,  and  assistance   in    the  diagnosis  Avill   be  gained   by  exploration 

through  the  anterior  wall  of  the  rec- 
tum by  means  of  the  finger  introduced 
through  the  anus.  If  any  swelling  or 
doughy  liardness  can  be  detected,  we 
should  endeavor  to  reach  it  tlirough  a 
free  incision  made  in  the  median  line 
of  the  perinanim.  This  can  do  no  harm, 
and  is  likely  to  be  of  essential  service. 
The  attempt  is  now  to  be  made  to 
relieve  the  bladder  by  the  passage  of 
a  metallic  or  gum-elastic  catheter 
through  the  stricture,  and,  in  difficult 
cases,  this  may  be  best  accomplished 
after  first  placing  the  patient  under 
the  influence  of  ether,  which  will 
greatly  tend  to  relax  spasm  and  re- 
lieve irritation.  Previous  acquaintance 
with  the  case  will  enable  the  surgeon 
to  form  some  idea  as  to  what  insti-u- 
ments  will  be  most  likely  to  prove 
successful.  Otherwise  he  will  first 
proceed  from  moderate  sized  catheters, 
both  metallic  and  flexible,  to  smaller 
ones  and  he  will  at  least  be  able  to  in- 
form himself  as  to  the  exact  situation  of 
the  obstruction.  If  these  instruments 
fail,  he  may  still  be  able  to  pass  a  fili- 
form bougie  of  gum,  whalebone,  or  cat-- 
gut,  which  will  serve  as  a  guide  to  a 
catheter  in  one  of  the  several  methods 
already  mentioned ;  or,  again,  if  only 
the  point  of  one  of  these  fine  bougies 
can  be  insinuated  within  the  orifice  of 
the  stricture,  and  allowed  to  remain 
for  a  few  moments,  a  small  stream  of 
urine  will  often  follow  its  withdrawal, 
and,  by  repeating  the  process,  the  en- 
tire contents  of  the  bladder  be  evacu- 
ated. 

In  these  cases,  Thompson's  "  probe- 
])ointed  catlieter"  (Fig.  lOG)  will  often 
be  found  of  service.  This  instrument 
is  a  catheter  "combining  tubuhir  con- 
struction with  minute  size,"  the  ex- 
tremity of  which  can  be  made  as  small 


Tbompson's  "  prole-rolnted  catheter. 


TREATMENT    OF    RETENTION    OF    URINE.  323 

as  the  finest  metal  probe,  and  is  solid  up  to  about  two  and  a  lialf  inches 
from  the  point,  where  the  eye  (*)  is  situated  ;  while  the  hollow  shaft 
above  gradually  enlarges,  first  to  No.  1,  and  then  nearly  to  No.  2.  A 
steel  rod,  capable  of  being  screwed  in  during  the  introduction  of  tlie  in- 
strument, gives  it  solidity,  and  prevents  the  eye  from  becoming  obstructed 
with  mucus  or  blood.  If  the  probe-pointed  extremity  can  be  passed 
through  or  fairly  within  the  stricture,  the  hollow  shaft  can  usually  in  a 
short  time  be  made  to  follow,  the  necessary  care  being  taken  to  avoid 
bending  the  point  upon  itself  or  engaging  it  in  a  false  passage. 

But  attempts  at  catheterism  may  be  prolonged  to  such  an  extent  as  to 
irritate  and  abrade  the  canal,  even  if  no  violence  be  used.  Many  cases 
also  come  under  the  care  of  the  surgeon,  in  which  instruments  have  already 
been  employed  to  excess  by  unskilful  hands,  and  in  no  gentle  manner ; 
and  in  which  the  urethral  walls  have  been  lacerated  or  false  passages  made. 
Hence  instrumental  interference  may  require  to  be  suspended,  or  for  a 
time  deferred. 

If  the  condition  of  the  bladder  will  admit  of  delay,  we  may  now  resort 
to  the  hot  bath  carried  to  the  verge  of  syncope,  as  previously  recom- 
mended. We  have  also  several  agents,  which  have  been  much  relied  upon, 
especially  befoi'e  the  invention  of  the  aspirator,  to  induce  micturition. 
The  cliief  of  these  is  opium,  which  was  thus  highly  spoken  of  by  Sir  Ben- 
jamin Brodie. 

"  From  half  a  drachm  to  a  drachm  of  laudanum  may  be  given  as  a  clyster 
in  two  or  three  ounces  of  thin  starch.  If  this  should  not  succeed,  give 
opium  by  the  mouth,  and  repeat  the  dose,  if  necessary,  every  hour  until 
the  patient  can  make  water.  According  to  my  experience,  the  cases  in 
which  the  stricture  does  not  become  relaxed  under  the  use  of  opium,  if  ad- 
mi  nistered  freely ,  are  very  rare.  The  first  effect  of  the  opium  is  to  diminish 
the  distress  which  the  jjatient  experiences  from  the  distention  of  the  bladder. 
Tlien  the  impulse  to  make  water  becomes  less  urgent;  the  paroxysms  of 
straining  are  less  severe  and  less  frequent ;  and  after  the  patient  has  been 
in  this  state  of  comparative  ease  for  a  short  time,  he  begins  to  void  his 
urine,  at  first  in  small,  but  afterwards  in  larger,  (juantities." 

The  muriated  tincture  of  iron  is  also  a  valuable  remedy  in  cases  of 
retention,  and  used  to  be  much  employed,  especially  at  the  New  York 
Hospital,  in  doses  of  fifteen  to  twenty  drops  every  half  hour.  Some  doubt 
has  been  thrown  upon  the  action  of  this  agent,  from  the  fact  that  it  is 
commonly  administered  in  conjunction  with  opium,  to  which  the  credit  in 
successful  cases  has  been  ascribed.  I  have  used  it  alone  in  several  in- 
stances with  very  favorable  results,  and  am  disposed  to  assign  it  a  position 
second  only  to  o[)ium  in  the  treatment  of  retention. 

Retention  of  urine  must  not,  however,  be  allowed  to  continue  too  long, 
since  even  in  the  absence  of  urgent  constitutional  symptoms,  "it  is  certain 
that  very  mischievous  consequences  result  from  extraordinary  distention 
(riq)tuie  of  the  urethra  and  extravasation  of  urine  being  passed  over,  as 
sufficiently  obvious),  in  its  effects  upon  the  kidney,  not  merely  in  the  way 
of  temporary  interference  with  the  performance  of  its  function  as  a  depu- 


321  STRICTURE    OF    THE    URETHRA. 

rating  organ,  but  in  the  lasting  injury  it  is  conceived  tliat  a  few  liours  of 
extreme  pressure  and  dilatation  may  exert  on  its  structure."  (Thompson.) 
The  least  suspicion  of  organic  renal  disease  should  make  us  doubly  careful 
in  this  regard. 

If,  then,  attempts  at  catheterism  have  been  continued  without  success 
as  long  as  can  be  regarded  as  consistent  with  safety,  the  question  arises, 
Shall  we  attack  the  retention  and  the  stricture  at  once  by  one  and  the 
same  operation,  or  shall  we  now  merely  empty  the  bladder,  leaving  the 
stricture  until  a  subsequent  period,  when  it  may  be  more  amenable  to 
treatment  than  at  present  ?  JSo  absolute  rule  can  be  laid  down  for  the 
decision  of  this  question,  since  each  case  must  be  considered  by  itself;  but 
it  may  be  said  in  general,  that  if  urethral  abscess  or  urinary  infiltration 
be  evidently  present,  or  even  strongly  suspected,  the  decided  indication  is 
to  approach  the  bladder  by  way  of  perineal  urethrotomy,  and  endeavor  to 
relieve  the  retention  and  remove  the  obstruction  at  the  same  sitting.  The 
different  operations  for  this  purpose  have  already  been  described. 

In  the  absence  of  urinary  infiltration  and  abscess,  the  retention  of  urine 
beiu""  the  only  pressing  symptom,  I  conceive  that,  in  most  cases,  it  is  best 
to  be  content  with  emptying  the  bladder  and  to  let  the  stricture  for  the 
time  being  alone,  provided,  always,  that  the  patient  is  within  convenient 
reach  of  the  surgeon,  so  that  further  measures  can  be  taken  at  any  moment 
if  required.  In  country  [)ract-ice,  where  the  surgeon  is  called  a  long  dis- 
tance from  home,  the  case  is  obviously  different. 

In  the  aspirator,  already  mentioned,  we  have  fortunately  an  instx'ument 
which  enables  us,  in  a  perfectly  simple  and  harmless  manner,  to  empty 
the  contents  of  the  bladder  through  a  puncture  above  the  pubes,  and  thus 
avert  any  danger  so  far  as  the  mere  retention  is  concerned ;  and  this  slight 
operation  may  be  repeated,  if  necessary,  in  the  hope  that  the  inflammation 
and  spasm  will  subside,  and  ihat  a  stricture  now  impervious  will  soon 
become  pervious,  or,  at  any  rate,  the  most  pressing  danger  will  have  been 
removed  and  time  gained  to  pre[»are  for  a  more  serious  operation,  if  required. 

The  aspirator,  as  originally  invented  by  Dieulafoy,  is  represented  in 
Fi<T.  107.  This  form  is  expensive,  and  is  now  generally  supplanted  by 
Totain's  modification  (Fig.  108),  which  is  sold  at  less  than  one-third  of 
the  price  of  the  former.  Moreover,  on  an  emergency,  the  surgeon  himself 
can  readily  fit  up  an  aspirator  by  attaching,  by  means  of  rubber  tubing,  a 
small  trocar,  provided  with  a  stopcock  to  prevent  the  entrance  of  air,  to 
the  suction-end  of  any  large  syringe — preferably  one  of  the  India-rubber 
syringes  of  Davidson  or  Mattson.  This  plan  was  first  suggested,  I  believe, 
by  Dr.  Gritti,  of  Milan. ^  Dr.  Andrew  H.  Smith, ^  of  New  York,  has  also 
devised  an  impromptu  aspirator,  in  which  the  suction  is  produced  by  the 
evaporation  of  ether.  It  consists  of  a  pint  bottle  with  a  tight  perforated 
cork,  fitted  with  a  glass  tube,  attached  to  which  is  rubber  tubing  with  a 
needle.     The  bottle  containing  one  or  two  drachms  of  ether  is  to  be  placed 

'  See  Med.  Rec,  N.  Y.,  181V>,  p.  7!K). 
2  Med.  Rec,  N.  V.,  Aug.,  1874,  p.  438. 


TREATMENT    OF    RETENTION    OF    URINE. 


325 


in  hot  water ;  when  all  the  ether  is  vaporized,  the  rubber  tube  is  to  be 
adjusted  and  tlie  trocar-needle  inserted  into  the  cavity  to  be  evacuated. 


Fig.  107. 


Dieulafoy's  aspirator. 


As  already  stated,  the  use 
of  the  aspii-ator  appears  to  be 
devoid  of  danger,  even  if  tlie 
trocar  passes  through  a  fold 
of  the  peritonaeum.  It  would 
appear  also  that  its  frequent 
repetition  is  equally  harm- 
less, since,  as  believed,  there 
is  no  authentic  case  on  re- 
cord in  which  mischief  has 
been  done.  In  one  instance, 
Guy  on*  performed  tvventy- 
three  aspirations  upon  the 
same  patient  in  eigiit  days, 
and  "the  most  simple  cathe- 
terization could  not  have 
been  more  harmless."  It 
need  only  be  added  tliat  this 
operation  is  almost  free  from 
pain,  and  does  not  require 
the  use  of  an  an;esthetic 
agent. 

Tlie  use  of  the  aspirator 
has  almost  if  not  quite  super- 
seded the  old  methods  of 
punctit.-ing  the  bladder.  The 
latter,  however,  may  receive  t>„,,;„-        •    . 

'  '  J        v.v^. .  <^  lotains  aspirator. 

'  DiKULAFOY,  Pneumatic  Aspiration  of  Morbid  Fluid.s,  London,  1873,  p. 


102. 


326 


STRICTURE    OF    THE    URETHRA. 


a  few  words  of  explanation,  in  case  they  should  be  called  for  in  the  absence 
of  the  proper  means  for  aspiration. 

Puncture  by  the  Rectain This  operation  is  inadmissible  in  case  the 

prostate  is  much  enlarged  from  iiy|)ertrophy  or  the  presence  of  a  tumor,  on 
account  of  the  danger  of  wounding  this  body  ;  also  if  the  bladder  be  greatly 
contracted,  since  the  trocar  may  perforate  its  anterior  as  well  as  posterior 
wall.  It  may  be  performed  with  an  ordinary  curved  trocar  and  canula, 
about  eight  inches  in  length,  but  it  is  an  advantage  to  have  the  former 
grooved,  so  as  to  indicate  with  certainty  by  the  flow  of  urine  wlicn  the 
point  has  entered  the  bladder. 


Fis.  109. 


Fiff.  110. 


Fig.  109.  Side  view  ofcamila  and  trocar.  1.  Eye  iu  the  former  c  )ni)iiuiiieatiug  with  the  groove 
in  the  latter.     2.   Rings  for  the  purpose  of  attachment.    3    Channel  lor  the  escape  of  urine. 

Fig.  11(1.  Trocar  seen  on  its  convex  aspect,  and  showing  the  groove,  which  is  converted  into  a 
tube  by  insertion  iu  the  cauula.     (.\ftor  Phillips.) 


The  patient  is  to  be  placed  as  in  the  operation  of  lithotomy,  with  an 
assistant  supporting  each  extremity.  The  lower  bowel  having  been  emptied 
hy  an  enema,  the  surgeon  introduces  his  left  forefinger,  well  oiled,  into  the 
rectum,  and  feels  for  the  recto-vesical  wall  just  back  of  the  posterior  margin 
of  the  prostate.  A  tap  upon  the  hypogastric  region  with  the  opposite  hand 
should  communicate  an  impulse  to  tlie  point  of  the  finger  in  the  rectum, 
and  this  is  to  be  regarded  as  indis[)ensable  before  proceeding  with  the 
o[)eiation.     The  canula  and   trocar  are  now  to  be  introduced  along  the 


TREATMENT    OF    RETENTION    OF    URINE. 


327 


finger  as  a  guide,  and,  while  an  assistant  compresses  with  l)Oth  hands  tlie 
lower  part  of  the  abdomen,  the  point  is  directed  forwards  exactly  in  the 
median  line,  and,  by  depressing  the  handle,  made  to  penetrate  into  the 
bladder,  the  accomplishment  of  which  may  be  known  by  its  freedom  in 
this  cavity  and  the  fiow  of  urine.  The  canula,  carefully  kept  in  place 
during  the  withdrawal  of  the  trocar,  is  to  be  fastened  by  a  T  bandage,  and 
may  be  retained  until  the  permeability  of  the  urethra  is  re-established. 


Fijr.  111. 


Recto-vesical  and  supni-pubic  puncture.     (After  Phillips.) 

The  risks  of  this  operation  are:  wounding  the  peritomeum  or  vesicular 
seminales;  consequent  peritonitis,  or  infiammation  of  the  appendages  and 
substance  of  the  testicle;  persistence  of  the  opening;  and  abscess  between 
the  rectum  and  bladder.  In  practice,  however,  these  results  rarely  follow. 
The  peritonaeum  is  too  high  up  to  be  much  exposed,  and  the  vesicuhe  .semi- 
nales may  be  avoided  by  adhering  closely  to  the  mcMlian  line.  The  recto- 
vesical puncture  has  been  known  to  remain  fistulous  for  life,  but  generally 
exhibits  a  strong  tendency  to  close  ;  and  the  formation  of  abscess  is  rare. 

Pu/icture  (ibore  the  Pahes Tiiis  o[)eration,  performed  with  an  ordinary 

trocar,  was  a  favorite  with  Abernethy,  an<l,  according  to  Dr.  Wilmot,' 
was  practised  by  Dublin  surgeons  in  preference  to  recto-vesical  puncture, 
but  has  not  been  so  generally  adopted  in  this  country  as  the  preceding 

•  Stricture  of  the  Urethra,  1858. 


328  STRICTURE    OF    THE    URETHRA. 

nietliofl.  Ir  is  entirely  inadmissible  when  the  bladder  is  contracted,  and 
ditficnlt  of  jierf'ormnnee  when  the  patient  is  corpulent;  though  in  spare 
subjects,  with  the  bladder  much  distended,  its  execution  is  very  easy.  The 
chief  danger  attending  it  is  from  infiltration  of  urine,  which  should  be 
guarded  against  by  making  a  free  external  incision,  and  by  leaving  the 
canula  in  place  for  twenty-four  or  thirty-six  hours,  and  until  lymph  has 
been  effused  around  it,  before  substituting  a  gum-elastic  instrument.  Fatal 
results  have  sometimes  ensued  from  sloughing  of  the  edges  of  the  wound, 
and  also  from  perforation  of  the  peritonaeum. 

In  performing  this  operation,  the  patient  should  be  placed  in  a  semi- 
recumbent  posture,  with  the  hair  shaved  from  the  pubes  ;  an  incision  is  to 
be  made  above  the  symphysis  involving  the  integument  and  cellular  tissue 
to  the  extent  of  about  two  inches  in  a  vertical  direction  ;  the  pyramidal 
muscles  may  now  be  separated  with  the  handle  of  the  scalpel,  and  the 
bladder  felt  for  by  a  finger  introduced  into  the  wound;  the  trocar,  either 
straight  or  slightly  curved,  with  its  concavity  downwards,  should  be  in- 
clined towards  the  lower  portion  of  the  sjicrum,  and  a  gum-elastic  catheter 
substituted  for  the  canula  at  the  end  of  one  or  two  days. 

Puncture  throvyh  the  Symphysis. — This  operation  has  been  too  infre- 
quently practised  to  admit  of  an  expression  of  opinion  regarding  it.  It 
was  first  proposed  by  Dr.  Brander,  in  1825,  and  since  performed  by  him  ; 
by  Dr.  Leasure,  of  New  Castle,  Pa.,  and  a  few  others.  Its  execution  is 
very  simple,  consisting  merely  in  introducing  a  trocar,  by  a  rotatory 
motion,  either  with  or  without  a  previous  incision  through  the  integument, 
between  the  pubic  bones,  in  the  direction  of  the  promontory  of  the  sacrum, 
and  afterwards  inserting  a  piece  of  flexible  catheter  through  the  canula. 
It  possesses  the  advantage,  as  suggested  by  Dr.  Leasure,  of  enabling  the 
surgeon,  in  the  absence  of  other  instruments,  to  relieve  retention  by  means 
of  a  simple  hydrocele  trocar. 

Opening  the  Urethra  posterior  to  the  Stricture This  is  best  done  in 

the  manner  described  u[)on  iiage  317,  when  sj)eaking  of  "  Cock's  opera- 
tion." At  a  meeting  of  the  Clinical  Society  of  London,  Oct.  25,  1878, 
Mr.  II.  G.  Howse  reported  a  noteworthy  case  of  traumatic  stricture,  in 
which  Cock's  operation,  performed  in  order  to  o\n'.\\  a  way  into  the  bladder, 
was  unsuccessful  in  conse(pience  of  a  dis[)lacement  of  the  urethra  from  its 
normal  position  and  the  formation  of  a  urinary  cul-de-sac.  Cystotomy 
from  the  perinaeum  through  the  prostate  gave  temporary  relief,  but  the 
normal  passage  of  the  urine  was  not  restored  until  a  supra-pubic  incision 
was  made  and  a  sound  passed  through  this  into  the  bladder  and  thence 
into  the  urethra,  to  serve  as  a  guide  for  perineal  section.' 

'  Reported  in  Tlie  Doctor,  London,  Nov.  1,  1878,  p.  230. 


treatment  of  urinary  abscess  and  fistula.        329 

Treatment  of  Extravasation. 

The  general  principles  upon  which  the  treatment  of  extravasation  of 
urine  is  to  be  conducted  are:  To  give  free  exit  by  incisions  to  the  escaped 
fluid  and  disorganized  tissues  ;  to  support  the  vital  powers  by  nourishnlent 
and  stimulants  ;  to  remove  and  render  inert  the  noxious  products  of  decom- 
position by  cleanliness  and  antiseptics.  At  the  earliest  moment  that  any 
external  symptoms  of  extravasation  can  be  detected — nay,  before  this,  if 
constitutional  shock  and  deep-seated  pain  lead  to  the  suspicion  of  the  es- 
cape of  urine,  although  its  presence  behind  the  deep  perineal  fascia  be  in- 
dicated by  no  sign  appreciable  upon  the  surface — a  free  incision  sliould  be 
made  in  the  median  line  of  the  perinaeum,  where  there  is  but  little  danger 
of  wounding  important  vessels.  When  the  extravasation  has  attained 
more  superficial  parts,  numerous  incisions  are  required  in  the  scrotum, 
and  wherever  else  there  is  distention  and  a  tendency  to  sloughing  or  gan- 
grene. 

We  are  generally  called  upon  to  sustain  the  sinking  powers  of  life  by 
the  free  exhibition  of  nourishment  and  stimulants ;  as  beef-tea,  brandy 
milk-punch,  carbonate  of  ammonia,  quinine,  etc.  Opium  is  of  value  when 
tliere  is  much  pain  or  nervous  irritability.  Nothing  can  be  done  for  the 
relief  of  the  stricture  during  tiie  continuance  of  the  shock  consequent  upon 
rupture,  but  usually,  as  this  passes  otF,  catheterism  may  be  successfully 
performed.  In  case  this  cannot  be  accomplished,  and  if  the  bladder  be 
found  on  percussion  to  be  still  distended,  owing  to  the  small  size  of  the 
rupture,  it  is  desirable  to  resort  to  puncture  at  once,  or  to  extend  the  in- 
cision in  the  perinanim  to  the  urethra  behind  the  obstruction.  The  dis- 
charge is  fetid  and  ammoniacal  from  the  first,  and  especially  so  as  the 
disorganized  tissues  are  cast  off  by  suppuration  ;  hence  frequent  ablutions, 
poultices  with  the  addition  of  Labarraque's  solution,  or  bags  of  powdered 
charcoal,  and  antiseptic  lotions  are  required. 

Treatment  of  Urinary  Abscess  and  Fistula. 

Urinary  abscess,  as  already  observed  in  the  present  chapter,  may  arise 
from  ulceration  of  the  urethra  and  consequent  escape  of  urine,  often  in 
minute  quantity,  into  tiie  cellular  tissue,  in  which  case  it  communicates 
with  the  canal  from  the  outset  ;  or  it  may  be  produced  by  simple  irritation 
of  the  neighboring  parts,  and,  although  isolated  at  first,  eventually  open 
into  the  urethra.  In  both  cases  the  sooner  the  abscess  is  evacuated  by 
external  incision,  the  better;  in  the  former,  in  order  to  quiet  the  constitu- 
tional disturl)ance  which  ordinarily  ensues,  an<l  prev(Mit  the  extension  and 
burrowing  of  matter;  in  the  latter,  to  effect  tin;  same  pur|)Ose,  and  also  to 
avoid,  if  possible,  any  lesion  to  tiie  urethral  walls  and  the  formation  of 
urinaftv  fistula;  ;  for  when  once  the  urine  h.as  found  an  abnormal  outlet,  it 
acts  as  a  constant  irritant,  and  renders  difficult  the  closure  of  the  passage 
either  by  nature  or  by  ait.      AVhcn  matter  is  pent  up  behind  the  triangular 


330  STRICTURE    OF    THE    URETHRA. 

ligament,  it  is  often  exceedingly  dilficult  to  detect  its  presence  by  external 
examination  ;  there  is  usually,  however,  even  in  obscure  cases,  some  degree 
of  hardness  and  tenderness  on  pressure,  and  if  its  existence  is  rendered 
probable  by  the  general  symptoms,  as  a  chill,  nausea,  rapid  pulse,  etc.,  an 
incision  should  at  once  be  made  in  the  median  line  of  the  perinanim  in 
front  of  the  anus  ;  even  if  pus  be  not  at  first  found,  a  passage  will  be 
formed  for  its  subsequent  exit,  and  the  tension  of  the  parts  will  be  relieved. 
In  some  exceptional  cases,  urinary  abscess  assumes  a  chronic  character, 
and  is  attended  by  little  febrile  excitement  or  inconvenience  ;  thus,  a  small 
tumor,  formed  by  an  abscess  communicating  with  the  urethra,  sometimes 
exists  for  months  before  being  discovered  by  the  patient  or  surgeon,  unless 
a  careful  examination  of  the  perina^um  be  made. 

Urinary  jistidce,  in  most  cases,  contract  and  close  spontaneously  when 
the  stricture  has  been  thoroughly  dilated,  especially  if  the  general  condition 
of  tlie  patient  be  maintained  at  a  pro|)er  standard  of  health.  Assistance 
may  be  derived  from  stimulating  applications  to  the  sinus;  as  of  nitrate  of 
silver,  nitric  acid,  tincture  of  cantharides  or  iodine,  etc.  The  end  of  a 
probe  may  be  coated  with  nitrate  of  silver  and  passed  along  the  fistulous 
track  ;  one  of  the  tinctures  just  mentioned,  eitlier  pure  or  diluted  witli 
water,  may  be  injected  :  and  plugs  of  compressed  sjjonge  may  occasionally 
be  inserted  to  advantage.  The  method,  however,  we  have  found  to  be 
most  successful,  is  first  to  thorouglily  cauterize  the  fistulte,  then  wait  for 
two  days,  after  which  the  urine  is  drawn  oft'  with  a  soft  catheter  every  time 
the  desire  to  pass  water  is  felt  and  the  patient  should  be  taught  to  do  this 
for  himself. 

Fistuhe  in  front  of  the  scrotum  frequently  require  plastic  operations,  a 
description  of  which  may  be  found  in  works  on  general  surgery. 

Proposed  Set  of  Urethral  Instruments. 

The  following  rather  generous  set  of  instruments  will  be  found  sufficient, 
in  nearly  all  cases,  for  the  exploration,  and  for  the  immediate  treatment, 
of  aflections  of  the  genito-urinary  organs.  Since  the  surgeon  is  often 
called  from  home  in  cases  of  emergency,  it  is  well  to  have  these  instru- 
ments fitted  into  trays  (two  are  sufficient,  each  about  thirteen  by  twelve 
inches).  These  trays  may  rest  upon  cleats  in  one  or  two  drawers  of  the 
office  table.  A  hand  valise  is  provided,  into  either  side  of  which  one  of 
the  trays  will  fit,  so  that  the  surgeon,  when  hurriedly  called  out,  has  only 
to  transfer  the  trays  from  the  drawls  to  the  valise,  and  he  is  sure  of  having 
all  his  instruments  with  him.  Without  this  arrangement,  he  is  usually 
subjected  to  the  expense  and  annoyance  of  having  a  double  set  of  instru- 
ments, one  for  office  and  the  other  for  outside  use. 

Maisonneuve's  urethrotome  (Fig.  92). 

Holt's  or  Voillemier's  rupture  instrument  (Figs.  97,  98). 

Author's  silver  catheter,  siz(;  No.  7,  Freucli,  witli  filit'Drm  bougie  conductor  (Fig. 

82). 
Six  filiform  bougies,  with  screw-heads  which  will  nicely  fit  any  and  all  of  the 

above. 


PROPOSED    SET    OF    URETHRAL    INSTRUMENTS.  331 

Thompson's  probe-pointed  catheter  (Fig.  106). 

Otis's  straight  dilating  urethrotome  (Fig.  95). 

Catheter-gauge,  either  Charriere-filiere  (Fig.  60),  or  Handerson's  gauge  (Fig.  62). 

Tape-measure. 

Set  of  acoru-ijointed  sounds,  seven  and  a  half  inches  long,  Nos.  12  to  40  (Fig.  70). 

Six  acorn-pointed  sounds,  curved,  alternate  Nos.  from  24  to  34  (Fig.  71). 

Otis's  (Fig.  75),  or  Weir's  urethrometer  (Fig.  76). 

One  or  two  meatometers,  ranging  from  Nos.  16  to  34  (Fig.  73). 

Twelve  steel,  nickel-plated  sounds,  Nos.  14,  16,  18,  20,  22,  24,  26,  28,  30,  32,  34, 

and  36,  their  points  conical  and  tapering  to  two  sizes  smaller  than  the  shaft, 

and  of  Thompson's  short  curve. 
Thompson's  searcher  for  stone. 

Two  silver-catheters,  Nos.  8  and  22,  Thompson's  curve. 
One  compound  catheter  (Fig.  63). 
Prostatic  catheter. 
Thompson's  urethral  forceps. 
Potain's  aspirator  (Fig.  108). 

Curved  trocar  and  canula  for  puncture  of  the  bladder  (Fig.  109). 
Syme's  staff  (Fig.  99). 
Silver  grooved  director,  9  in.  long. 
Otis's  staff  for  Jaque's  flexible  catheter  (Fig.  65). 
Probe-pointed  meatotome  (Fig.  84). 
Phimosis  forceps  (Fig.  26). 
Sands's  artery  forceps. 
Strong,  blunt-pointed  scissors  (Fig.  25). 
Ear-syringe  of  hard  rubber,  the  nozzle  of  which  unscrews  and  allows  Taylor's 

phimosis  nozzle  (Fig.  25)  to  be  attached. 
Straight  bistoury  and  tenaculum. 
Box  containing  vaseline. 
"  "  needles  and  ligatures. 

"  "  suppositories  of  morphine  and  belladonna. 

"  "  styptic  cotton. 

A  few  fine  flexible  bougies,  whalebone  bougies,   flexible  catheters   and  Jaque's 

catheter  (Fig.  64). 
Hypodermic  syringe. 
"Thermometer. 

N.  B. — The  danger  of  communicating  disease  from  one  patient  to  another  by 
means  of  urethral  instruments,  especially  those  M'hose  grooves  or  joints  may  harbor 
septic  matter,  should  never  be  forgotten.  All  instruments  should  be  scrupulously 
cleansed,  and  metallic  ones  be  plunged  for  a  few  minutes  into  boiling  water,  before 
they  are  used  again.  Moreover,  the  lubricant  employed  should  contain  a  disin- 
fectant, as,  for  instance,  ten  drops  of  the  "impure  carbolic  acid"  to  each  ounce  of 
oil  or  vaseline. 


332  SEXUAL  HyrocnoNDRiAsis. 


CHAPTER    XXV. 
SEXUAL   HYPOCHONDRIASIS. 

No  small  proportion  of  the  patients  Avho  apply  at  the  office  of  the  vene- 
real specialist,  are  afflicted  only  with  hy[)Ochondriasis  relating  either  to 
the  appearance  or  the  functions  of  their  genital  organs.  These  patients 
may  be  divided  into  two  classes:  first,  those  who  are  ignorant  of  what 
the  appearances  of  the  genital  organs  normally  are,  or  how  far  tliese  ap- 
pearances vary  in  sound  persons,  or  who  are  ignorant  of  the  influences 
which  affect  the  function  of  these  organs  in  all  men,  even  the  most  healthy. 
This  class  of  patients,  if  blessed  with  common  sense  and  confidence  in 
their  medical  adviser,  need  only  information  to  set  them  all  right. 

But  there  is  a  second  class  of  such  patients,  unfortunately  the  more 
numerous,  whose  minds  are  really  unsound  in  reference  to  their  sexual 
organs  ;  who  are  unwilling  to  accept  the  statement  of  their  physician  that 
there  is  nothing  the  matter  with  them  ;  who  go  on  brooding  over  their 
imaginary  trouble  ;  who  fall  the  ready  victims  of  quacks  ;  and  who,  after 
leading  a  miserable  existence,  a  burden  to  themselves  and  their  friends, 
sometimes  become  the  inmates  of  a  lunatic  asylum,  or  seek  a  suicide's 
death.  If  such  patients  cannot  l)e  made  to  listen  to  reason,  and  a  manly 
spirit  cannot  be  roused  up  in  tliem,  there  is  no  hope  for  them,  for  neither 
medicine  nor  surgery  can  cure  them.  I  propose  to  mention  some  of  the 
grounds  of  com})Iaiut  which  the  subjects  of  sexual  fear  or  hy})Ochondriasis, 
most  commonly  set  forth  to  their  physician. 

With  some,  the  com[)laint  is  almost  ludicrous,  as,  for  instance,  that  one 
testicle  hangs  lower  than  the  other — a  condition  which  obtains  with  the 
great  majority  of  men  ;  or  the  patient  thinks  that  his  penis  or  testicles  are 
smaller  than  they  ought  to  be,  even  when  they  are  of  very  fair  dimensions; 
or  he  complains  of  an  itching  or  crawling  sensation  in  the  parts,  which  is 
not  strange  while  his  thoughts  are  constantly  directed  upon  them.  Again, 
it  is  the  cheesy  excretion  which  forms  in  the  furrow  at  the  base  of  the 
glans  ;  a  few  herpetic  vesicles  appearing  from  time  to  time,  or  a  slight 
eczema  of  the  penis  or  the  eczema  marginatum  which  is  so  often  developed 
in  the, inguinal  fold,  that  makes  him  unhappy.  A  prominent  professional 
man  applied  to  me  a  few  years  ago  for  a  little  follicular  abscess  on  the 
sheath  of  the  penis,  which  he  kept  open  by  constantly  picking  at  it.  His 
mind  was  perfectly  clear  on  every  other  subject  but  was  insane  on  this. 
He  imagined  he  had  syphilis  and  had  communicated  it  to  his  wife  and 
children.  After  a  few  months  he  committed  suicide.  Again,  enlargement 
of  the  scrotal  veins,  or  varicocele,  is  a  fruitful  source  of  terror  to  many  men. 


SEXUAL    HYPOCHONDRIASIS.  333 

This,  indeed,  may  exist  to  such  an  extent  as  to  seriously  incommode  the 
patient  and  to  demand  surgical  interference  ;  but,  in  a  moderate  degree,  it 
is  of  trivial  moment,  and  may  be  relieved  by  wearing  a  suspensory  ban- 
dage. 

But  nocturnal  emissions  are  the  complaint  of  most  of  the  subjects  of 
sexual  hypochondriasis,  and  these  they  will  jii'obably  ascribe  to  masturba- 
tion, which  they  ignorantly  practised  for  a  time  in  former  years,  until  they 
had  visited  one  of  the  vile  "  Musajums  of  Anatomy"  which  infest  our 
cities,  and,  either  there  or  elsevi'here  had  read  the  terrible  pictures  of  the 
dire  effects  of  this  habit,  which  quacks  are  wont  to  conjure  up.  Their 
emissions  did  not  occur  until  after  they  had  abandoned  self-abuse,  and 
hence,  with  illogical  reasoning,  they  "•  must  be  due  to  that  practice."  Even 
men  in  adult  life,  who  have  been  left  widowers  after  years  of  unimpaired 
sexual  power,  will  ascribe  nocturnal  emissions  due  to  their  present  conti- 
nence, to  early  indiscretion.  The  subjects  of  nocturnal  emissions  will  tell 
you  that,  after  each  emission,  they  feel  weak  and  exhausted  ;  that  they 
iiave  pain  in  the  back  ;  and  that  they  find  their  memory  failing.  They 
are  apt  to  imagine,  also,  that  the  natural  moisture  of  the  urethra  is  semen  ; 
that  the  viscid  fluid  which  oozes  from  the  canal  on  sexual  excitement  is 
semen,  and  that  they  pass  semen  on  straining  at  stool  or  in  their 
urine — the  latter  being  shown  by  some  shreds  which  it  contains  when 
rirst  passed  or  by  the  sediment  which  is  formed  on  standing. 

Now  these  men  are  to  be  told  some  plain  truths.  Nocturnal  emissions 
occur  independently  of  the  practice  of  masturbation.  Some  of  the  most 
frequent  cases  I  have  ever  seen  have  been  in  men  who  had  never  com- 
mitted self-abuse.  They  are  incident  to  early  manhood,  especially  between 
the  ages  of  fifteen  and  thirty,  and  are  less  frequent  as  life  advances.  At 
this  period,  the  genital  functions  are  most  active  ;  the  secretion  of  semen 
is  constantly  going  on,  and  must  find  vent  somewhere,  like  a  loaded  rectum 
or  a  distended  bladder.  For  a  man  in  the  prime  of  life,  and  living  coi.- 
tinently,  not  to  have  an  occasional  nocturnal  emission,  is  a  rare  exception. 
The  frequency  of  these  emissions  will  vary  and  yet  be  consistent  witii 
health,  and  will  depend  somewhat  u})on  the  purity  of  the  thoughts  of  the 
individual,  and  upon  whether  the  sexual  desires  have  already  been  excited, 
as  by  masturbation,  illicit  sexual  intercourse,  or  the  marriage  state.  Hence 
niasturbators  and  widowers  will  be  more  exposed  to  them  than  those  who 
have  been  continent  from  tlieir  youth  up.  With  regard  to  their  frequency, 
it  may  be  said  in  general,  that  once  a  month  or  once  a  fortnight  is  most 
common,  but  they  may  take  j)lace  as  often  as  two  or  three  times  a  week 
without  detriment  to  the  health.  They  are  very  aj)!  to  occur  in  groups — 
and  this  is  a  point  to  be  mentioned  to  {)atients — i.  e.,  he  may  be  free  from 
them  for  several  weeks  and  then  will  have  two  or  three  on  successive  nights 
or  the  same  night. 

In  njnety-nine  cases  out  of  one  hundred,  these  emissions  require  no 
medical  or  surgical  treatment.  The  chief  danger  from  them  lies  in  the 
j)atient's  attaching  undue  importiince  to  them,  in  dwelling  ui)on  them,  and 


334  SEXUAL    HYPOCHOxXDRIASIS. 

niakiiiLr  himself  miserable  over  tliem.  It"  he  can  be  induced  to  give  his 
mind  and  body  pure  thoughts  and  healthy  exercise,  and  to  look  upon  their 
occurrence  as  a  physical  necessity,  nature  will  take  care  of  the  rest. 

It  is  now  many  years  ago  since  a  young  man,  who,  like  most  young 
men,  had  not  been  entirely  free  from  self-abuse,  picked  up  a  small  pam- 
phlet written  by  the  late  Dr.  Bell,  superintendent  of  the  McLean  Insane 
Asylum,  in  which  the  sin  and  degradation,  and  the  evils  of  masturbation 
were  set  forth.  He  at  once  abandoned  the  habit,  but  nocturnal  emissions 
occurred  and  became  a  terror  to  him.  He  called  upon  Dr.  Bell,  and  his 
tirst  words,  after  announcing  his  mission,  were  to  thank  him  for  writing 
the  pam[)hlet  he  had  read.  To  his  surprise,  Dr.  B.  replied  that  he  was 
sorry  he  had  ever  written  it ;  that  the  first  edition  was  exhausted,  and 
that  he  would  never  allow  another  to  be  published.  ''  Why  ?"  "  Because 
I  believe  that  what  I  said  o^ the  possilj/e  evils  of  masturbation  and  nocturnal 
emissions  was  overdrawn,  and  has  done  more  harm  by  the  fears  it  has 
excited  in  young  men,  than  a  continuance  of  the  practice  itself  would 
have  done."  "Well,  what  medicine  shall  I  take?"  "No  medicine 
whatever"  (second  surprise  of  the  young  man).  "  I  shall  only  lay  down 
some  hygienic  rules  for  you  to  follow.  You  must  expect  your  nocturnal 
emissions  to  occur  from  time  to  time,  but  must  not  mind  them.  They  will 
be  less  and  less  frequent  as  you  grow  older,  and,  if  you  ever  get  married, 
they  will  cease."  The  young  man  had  strength  of  mind  enough  to  appre- 
ciate this  advice  and  follow  it.  He  found  every  word  of  the  doctor's 
prognosis  in  his  case  to  come  true,  and  in  hundreds  of  such  cases  which  he 
afterwards  met  with  in  practice  when  himself  a  physician,  the  same  advice, 
when  accepted  and  followed,  always  proved  successful. 

As  intimated  above,  matrimony  might  be  regarded  as  the  best  prescrip- 
tion in  cases  of  nocturnal  emissions,  and  it  t's  the  best  prescription  when- 
ever practicable  under  such  conditions  of  mutual  attachment,  etc.,  which 
are  necessary  to  make  married  life  hapi)y.  To  marry  simply  for  the  sake 
of  sexual  intercourse,  is  likely  to  lead  to  greater  unhappiness  than  can 
ever  be  caused  by  nocturnal  emissions. 

Illicit  sexual  intercourse,  as  a  substitute  for  matrimony,  is  never  to  be 
recommended  ;  first,  because  it  is  morally  wrong,  and  the  physician  would 
take  upon  himself  a  fearful  responsibility  in  advising  it ;  and  second, 
l)ecause  the  excesses  which  fornication  always  leads  to,  have  an  effect 
directly  opposite  to  the  one  desired.  In  an  admirable  lecture'  on  sexual 
hypochondriasis,  Sir  James  Paget  says  :  "  Many  of  your  patients  will  ask 
you  about  sexual  intercourse,  and  some  will  expect  you  to  prescribe  forni- 
cation. I  would  just  as  soon  prescribe  theft  or  lying,  or  anything  else  that 
God  has  forbidden.  If  men  will  practise  fornication  or  uncleanness,  it 
must  be  of  their  own  choice  and  on  their  sole  responsibility.  We  are  not 
to  advise  that  which  is  morally  wrong,  even  if  we  have  some  reason  to 
think  a  patient's  health  would  be  better  for  the  wrong-doing.  But  in  the 
cases  before  us,  and  I  can  imagine  none  in  which  I  should  think  difFer- 

■'  Clinical  Lectures  and  Essays  by  Sir  James  Paget,  London,  1875. 


SEXL'AL    HYPOCHONDRIASIS.  335 

ently,  tliere  is  not  ground  enough  for  so  mucli  as  raising  a  question  about 
wrong-doing.  Chastity  does  no  harm  to  mind  or  body ;  discipline  is 
excellent ;  marriage  can  be  safely  waited  for ;  and  among  tlie  many 
nervous  and  hypochondriacal  patients  who  have  talked  to  me  about  forni- 
cation, I  have  never  heard  one  say  that  he  was  better  or  happier  for  it ; 
several  have  said  they  were  worse  ;  and  many,  I  know,  have  been  made 
worse." 

In  all  cases  of  frequent  nocturnal  emissions,  the  genital  organs  should 
be  examined,  and,  whether  phimosis  exists  or  not,  if  the  prepuce  be  loner 
and  redundant,  circumcision  is  to  be  recommended  (see  chapter  on  Phimo- 
sis). A  very  marked  varicocele  may  also  render  surgical  interference 
desirable. 

The  hygienic  rules  to  be  given  to  the  patient  are  very  simple.  It  is 
better  that  the  most  substantial  meal  in  the  twenty-four  hours  should  be 
taken  at  noon  ;  the  supper  should  be  light,  and  food  and  drink  be  entirely 
avoided  in  the  evening;  the  bedchamber  should  be  well  ventilated,  a  hair 
mattress  preferred  to  a  feather  bed,  and  much  covering  avoided ;  the 
l)atient  should  sleep  upon  his  side  and  not  upon  the  back  ;  a  small  pillow 
placed  between  the  knees,  so  as  to  separate  the  thighs  and  prevent  the 
scrotal  organs  from  becoming  heated,  is  sometimes  desirable;  and^the 
patient  should  rise  as  soon  as  he  wakes,  emissions  occurring  most  fre- 
quently during  the  semi-consciousness  of  the  early  morning  nap.  Tobacco 
in  every  form  should  be  prohibited,  since  it  not  only  increases  the  general 
irritability  of  the  nervous  system,  but  appears  to  have  a  direct  influence 
in  diminishing  the  tone  of  the  genital  organs  and  thus  favoring  seminal 
emissions.  Above  all,  as  already  stated,  the  mind  of  the  patient  should 
be  distracted  from  his  complaint  by  constant  occupation,  and  his  genex-al 
health  be  i)romoted  by  a  plain  but  nourishing  diet  and  by  daily  out-door 
exercise,  not  carried  to  fatigue,  since  it  is  found  by  experience  that  when 
the  strength  is  exhausted  an  emission  is  more  likely  to  occur.  Many  of 
these  patients  also  have  constipated  bowels,  and  means  should  be  taken 
to  secure  a  daily  stool. 

As  a  rule,  no  other  measures  than  the  above  are  required.  It  is  to  be 
understood,  however,  that  any  weakness  of  the  genital  organs  is  often  only 
one  manifestation  of  a  general  weakness  and  irritability  of  the  nervous 
system,  which  may  require  the  administration  of  tonics,  a  change  of 
climate,  etc.  For  this  purpose  I  have  found  the  two  following  prescriptions 
of  good  service  : — 

B.     Ferri  et  Quiiii<e  Citrat.,  ^iij      ...       12'     ' 

Strychiiije  Siili)li.,  gr.  j 106 

Acidi  Pliospliorif.  (lilut.,  §.ss     ...       15 

Hyrp.  Aiiraiitii,  §ij 80 

Aquain,  ad  §iv 145| 

M.  et  sig. — A  teaspoonfu)  (5.00)  in  water  afti-r  each  meal. 

R.     Stiyclmiffi  Snlpli.,  gr.  j t06 

Acidi  Phospli.  dilut.  ,^iij 90 

M.  et  sig.—  A  teaspoonful  (.'3.00)  tliree  times  a  day  after  eating. 


336  SEXUAL    HYPOCHONDRIASIS. 

TIic  tincture  of  the  chloride  of  iron  and  also  ergot  have  been  supposed, 
and  I  think  justly  so,  to  have  a  special  tonic  effect  upon  the  genital  organs, 
but  they  must  be  given  in  large  doses,  as  for  instance  from  half  a  drachm 
to  a  drachm  (2.00-4.00)  of  either  the  tincture  of  iron  or  the  fluid  extract 
of  ergot  (Squibb's)  in  water  after  each  meal.  They  may  be  combined  as 
in  the  following  prescription  ; — 

R.     Tr.  Ferri  Chloridi,  §ii.i 901 

Ext.  Ergot;e  fl.  (Squibb's),  giij       .     .     .     f)o| 
M.  et  sig — .A  teaspoonful  (4.00)  in  water  after  eacli  meal. 

As  a  direct  means  of  diminishing  the  frequency  of  the  emissions,  how- 
ever, tlie  following  is  often  found  to  be  most  efficacious: — 

IJl.     Potassii  Bromidi,  §j 30 

Tr.  Ferri  Chloridi,' §j 30 

Aqu?e,  5iij 90 

M.  et  sig. — From  one  to  two  teaspoonfuls  (4.00-8.00)  in  water  after  each  meal 
and  at  bedtime. 

Mention  has  already  been  made  of  the  advisableness  of  circumcision 
when  the  prepuce  is  long.  It  may  also  be  found  u[)on  the  introduction  of 
a  sound  that  the  urethra  is  over-sensitive,  especially  in  the  prostatic  region. 
In  such  cases,  the  introduction  of  a  cold  sound  of  full  size,  at  first  every 
thii'd  or  fourth  day  and  afterwards  with  greater  frequency,  will  generally 
at^ord  relief  to  the  hypera?sthesia.  I  sometimes  inject  into  the  prostatic 
urethia  about  ten  drops  of  a  solution  of  nitrate  of  silver  of  the  strength  of 
twenty  grains  (1.30)  to  the  ounce  (30.00)  of  water,  by  means  of  my  deep 
urethral  syringe  or  Guyon's  flexible  catheter  and  syringe.  The  severe 
cauterization  with  the  porte-caustique  of  Lallemand,  should,  by  all  means, 
be  avoided.  In  one  severe  case  of  nocturnal  emissions  occurring  several 
times  every  night,  Prof.  J.  PI.  Pooley'  made  a  perineal  incision,  similar  to 
that  for  median  lithotomy,  into  the  urethra  just  at  the  apex  of  the  prostatic 
gland,  and  diverted  the  urine  from  its  natural  channel.  The  result  was 
successful,  but  whether  due  to  the  mental  or  physical  effect  of  the  o})eration 
may  be  a  question. 

A  few  words  are  still  necessary  with  regard  to  the  special  complaints 
made  by  these  patients  to  their  medical  adviser,  and  which  have  for  the 
most  part  been  enumerated.  Trifling  as  they  may  appear  to  him,  they 
should  yet  be  fully  explained  to  them.  The  lassitude  and  backache  which 
they  experience  after  an  emission,  is  nothing  more  than  any  person  of  im- 
paired nervous  power  would  feel  after  a  long  walk  or  other  exercise. 
Their  "loss  of  memory"  is  purely  imaginary.  They  should  be  told  that 
the  natural  condition  of  the  urethra  is  one  of  moisture,  like  the  inside  of 
the  mouth  ;  that  the  amount  of  moisture  will  vaiy  at  different  times;  that 
it  is  especially  liable  to  be  increased  by  the  erethism,  occurring  either  with 
or  without  the  knowledge  of  the  patient  during  the  hours  of  sleep,  and 
hence  is  most  perce[)tible  in  the  morning  on  rising;  that  it  is  perfectly 
natural  in  men,  as  in  the  lower  animals,  to  have  the  end  of  the  penis  smeared 

'  N.  Y.  J.  Med.,  vol.  xxviii,  1878,  p.  302. 


SEXUAL    HYPOCHONDRIASIS.  337 

witli  a  clear,  viscid  fluid  when  under  sexual  excitement  (nature's  object 
probably  beinjr  to  facilitate  intromission)  ;  that  a  cloud  or  sediment  will  form 
in  the  most  normal  urine  when  allowed  to  stand  for  a  few  hours,  and  that 
no  pair  of  o|)tics  ever  born,  unassisted  by  the  microscope,  could  discover 
the  presence  of  semen.  But  even  should  it  occur,  as  it  sometimes  does, 
that  a  fluid  actually  containing  spermatozoa  is  pressed  out  from  the  canal, 
especially  on  straining  in  passing  a  hard  stool,  it  is  nothing  more  than  that 
overflow  from  the  vesiculae  seminales  to  which  continent  persons  in  robust 
health  are  liable.  Spermatozoa  left  in  the  canal  after  such  exertion,  and 
particularly  after  a  wet  dream  during  the  night,  will  naturally  be  washed 
away  by,  and  be  found  in,  the  urine  the  next  time  it  is  passed. 

The  picture  that  I  have  given  of  masturbation  and  seminal  emissions  is 
very  different  from  the  one  drawn  by  Lallemand  and  by  the  charlatans  of 
the  present  day,  who,  in  their  circulars,  represent  impotence,  disease  of  the 
lieart,  consumption,  paralysis,  insanity,  and  idiocy  as  a  few  of  the  conse- 
quences of  self-abuse,  which  can  only  be  cured  by  some  nostrum  of  which 
they  hold  the  secret.  Masturbation  is  injurious,  degrading,  and  beastly 
enough,  not  to  require  to  be  painted  in  any  colors  which  are  not  consistent 
with  truth.  I  have  taken  occasion  to  make  inquiries  of  some  of  the  most 
eminent  physicians  of  our  insane  asylums,  as  to  what  extent  masturbation 
should  be  regarded  as  a  cause  of  insanity,  and  they  have  expressed  the 
decided  opinion  that  it  was  mental  weakness  that  led  to  masturbation  and 
not  masturbation  that  led  to  mental  weakness  and  insanity. 

Paget's  words  on  this  [)oint  are  worth  cpioting:  '•  You  mav  teach  posi- 
tively that  masturbation  does  neither  more  nor  less  harm  than  sexual 
intercourse  pnxctised  with  the  same  frequency  in  the  same  conditions  of 
general  health  and  age  and  circumstance.  Practised  frequently  by  the 
very  young,  that  is,  at  anytime  before  or  at  the  beginning  of  jjuberty, 
masturbation  is  very  likely  to  produce  exhaustion,  effeminacy,  over-sen- 
sitiveness and  nervousness;  just  as  equally  frequent  copulation  at  the  same 
age  would  probably  produce  them.  Or,  practised  every  day,  or  nifiny 
times  in  one  day,  at  any  age,  either  mastiuljation  or  copulation  is  likely 
to  produce  similar  mischiefs  or  greiiter.  An<l  the  mischiefs  are  especially 
likely  or  nearly  sure  to  happen,  and  to  be  greatest,  if  the  excesses  are 
l)ractised  by  those  who,  by  inheritance  or  circumstances,  are  liable  to  any 
nervous  disease, — to  "spinal  irritation,"  epile|)sy,  insanity,  or  any  other. 
But  the  mischiefs  are  due  to  the  quantity,  not  to  the  method,  of  the  ex- 
cesses ;  and  the  quantity  is  to  be  estimated  in  relation  to  age  and  the  power 
of  the  nervous  system.  I  have  seen  as  numerous  and  as  great  evils  con- 
sequent on  excessive  sexual  intercourse  as  on  excessive  masturbation  ;  but 
I  have  not  seen  or  heard  anything  to  make  me  believe  that  occasional 
masturbation  has  any  other  eflects  on  one  who  practises  it  than  has  sexual 
intercourse,  nor  anytiiing  justifying  the  dread  witli  which  sexual  hypo- 
chondrirfts  regard  the  iiaving  occasionally  practised  it.  I  wish  I  could 
say  sometiiing  worse  of  so  nasty  a  practice  ;  an  uncleanliness,  a  filthiness 
foibidden  by  God,  an  unmauliness  despised  by  men." 

There  are  other  complaints  of  the  sexual  hypochondriac,  into  which  we 
have  not  the  space  fully  to  enter.    I  refer  particularly  to  those  odd  caprices 
22 


338  SEXUAL    HYPOCHONDRIASIS. 

which  these  organs  sometimes  exhibit  under  varying  mental  emotions, — 
even  in  the  most  robust  and  heaUhy  individuals.  Perhaps  the  most  frecjuent 
comphxint  is  that  of  too  speedy  ejaculation,  which  may  take  place  on 
attempting  intercourse  with  any  woman  or  with  some  one  woman  in  par- 
ticular, especially  if  the  attempt  be  the  first  one  witli  her.  Here  the  mind 
is  chiefly  at  fault :  over-anxiety  to  perform  the  act  well  is  very  likely  to 
lead  to  its  being  performed  badly.  Tt  occurs  less  frequently  in  married 
life  than  in  single,  and  is  a  defect  which  diminishes  with  age,  as  old  men 
Avell  know.  If  art  can  do  anything  to  hasten  its  cure,  it  will  be  by  means 
already  mentioned  ;  circumcision  if  rhe  prepuce  be  long  ;  the  cold  sound 
in  cases  of  irritability  of  the  prostate,  ergot  and  the  tincture  of  iron  in- 
ternally ;  last,  but  not  least,  matrimony,  or,  in  lieu  of  that,  some  other 
object  in  life  than  sexual  gratification. 

Cases  of  absolute  impotence  in  men  of  good  health  and  who  have  not 
greatly  abused  their  powers,  must  be  rare  ;  I  can  recall  but  three  or  four 
in  many  years  of  practice.  These  I  have  treated  with  almost  every  reme- 
dy which  I  had  ever  heard  of,  but  I  never  found  any  benefit  accrue  to  the 
patient.  Most  frequently  the  impotence  is  merely  imaginary.  It  is  safe 
to  tell  any  man  who  has  erections  at  night  that  he  is  not  impotent.  Matri- 
mony is  the  remedy  for  this  imaginary  evil,  but,  like  the  boy  wdio  did  not 
want  to  go  into  the  water  until  he  first  knew  how  to  swim,  the  patient 
desires  to  be  satisfied  beforehand  of  his  competency.  This  he  cannot  do 
by  trial  with  women  of  the  town  :  the  conditions  under  which  such  at- 
tempts are  made  are  obviously  so  different  from  those  of  married  life  as  to 
require  no  comment. 

Finally,  the  satisfactory  accomplishment  of  the  sexual  act  will  be  in- 
fluenced by  the  merest  whim  or  fancy.  One  man  will  be  told  by  a  friend 
some  story  of  his  sexual  weakness,  and,  with  this  in  his  memory,  he,  too, 
for  a  time  will  find  himself  defective.  A  coarse  word  or  some  persoi^al 
remark  made  by  a  woman  may  take  away  all  desire  for  her,  while  the 
power  remains  the  same  with  others.  Excessive  desire,  especially  with 
gratification  long  delayed,  may  also  temporarily  deprive  a  man  of  his 
power.  Eoubaud'  relates  a  story  of  a  young  Frenchman  living  in  the 
country  where  he  was  initiated  into  the  pleasures  of  Venus  by  a  governess, 
who  was  a  blonde,  and  always  wore  when  she  met  him  English  boots, 
corsets,  and  a  silk  dress.  When  old  enough,  it  became  desirable  for  fjimily 
reasons  that  he  should  be  married,  but  he  found  himself  impotent  except 
under  the  above  named  conditions  :  the  woman,  at  the  time  of  connection, 
must  be  dressed,  must  be  of  a  blonde  complexion,  must  wear  English  boots, 
corsets,  and  a  silk  dress,  in  wliich  case  his  powers  were  as  great  as  could 
be  desired.  Under  the  pretence  of  giving  him  a  powerful  medicine,  Rou- 
baud  administered  a  "  placebo"  which  cured  him.^  This  story  is  here 
told  to  show  how  much  a  man's  powers  are  influenced  by  his  mental  con- 
dition, and  to  enforce  the  importance  of  paying  attention  to  the  morale  as 
w^ell  as  the  physique  in  the  treatment  of  disorders  of  the  genital  functions. 

'  Traite  de  I'impuissance  et  de  la  sterilite,  3d  ed.,  1876,  p.  371. 

2  This  story  reminds  one  of  another  concerning  a  sailor,  who  was  so  accustomed 
to  passing  his  water  over  a  railing  into  tlie  sea,  that,  when  on  shore,  he  could  only 
relieve  his  bladder  by  piddling  into  a  well. 


PART  II. 
THE  CHANCROID  AND  ITS  COMPLICATIONS. 


CHAPTER    I. 
THE   CHANCROID,    OR   SIMPLE   CHANCRE. 

I  ADOPT  the  name  of  "  chancroid"  to  designate  the  "contagious  and 
local  ulcer  of  tlie  genitals,"  the  history  of  which  has  been  given  in  tlie  In- 
troduction of  the  present  work. 

Among  the  most  important  names  which  have  been  given  it,  especially 
in  modern  times,  are  the  "simple,"  "  soft,"  "non-infecting,"  or  "non- 
indurated  chancre"  by  various  authors;  the  "chancrelle"  by  Diday;  and 
the  "chancre"  by  Hebra,  Zeissl,  Reder,  and  others  of  the  modern  German 
school.  Hence  tlie  student  will  observe,  when  reading  German  authors, 
that  "a  chancre"  spoken  of,  means  what  we  here  call  "chancroid." 
What  we  here  call  a  "  true  chancre"  is  designated  by  the  Germans  as  "  the 
initial  lesion  of  syphilis,"  as  it  truly  is.  The  nomenclature  followed  in 
this  work  is,  however,  the  one  usually  adopted  in  this  country. 

Most  modern  French  authors  designate  this  disease  as  the  "simple 
chancre,"  in  contradistinction  to  the  "syphilitic  chancre,"  the  initial 
lesion  of  syphilis  ;  and,  unless  the  term  "  chancroid,"  now  so  commonly 
recognized,  be  adopted,  this  name  appears  to  be  the  most  acceptable. 
Lancereaux  calls  it  '■'■false  or  local  syphilis.^"  Its  secretion  may  be  taken 
up  by  the  lymphatics  and  conveyed  to  the  nearest  ganglion,  there  to  set  up 
inflammation  and  the  formation  of  matter  possessing  the  same  power  of 
reproduction  as  the  secretion  of  the  sore  itself;  but  its  farther  progress  is 
arrested  within  the  ganglion ;  it  never  gains  access  to,  nor  contaminates 
the  general  circulation ;  and,  since  its  influence  is  thus  confined  to  the 
neighborhood  of  the  })oint  of  implantation  of  the  virus,  it  must  be  regarded 
as  a  local  disease. 

TiiK  Chancroidal  Poison In  the  Introduction  to  the  present  work, 

reasons  have  been  set  forth  to  show  that  the  chancroid  is  not  dependent 
upon  a  specific  virus,  in  the  same  sense  that  we  attach  to  the  word  "virus" 
when  speaking  of  syphilis  or  variola.  That  it  possesses  a  contagious  element 
or  poison  is  uncpiestionable,  but  we  believe  that  this  poison,  under  certain 
conditions  and  especially  when  the  products  of  simple  inflammation  have 


340  CHANCROID. 

undergone  decom|)Osition  and  are  inoculated  upon  persons  in  a  debilitated 
state,  is  cajtab/e  of  being  generated  de  novo,  and  may  then  be  transmitted 
to  other  individuals.^  That  such  an  occurrence  \&  frequent  in  sexual  inter- 
course we  do  not  claim,  and  we  expect  to  find  a  chancroid  in  that  person 
of  the  opposite  sex  with  whom  a  patient  api)lying  to  us  with  a  chancroid 
has  had  intercourse;  but  that  it  may  and  does  take  place,  however  rarely, 
the  experiments  already  detailed  appear  to  leave  no  doubt.  Moreover, 
this  supposition — if  any  one  prefers  to  call  it  so — better  explains  the 
different  degrees  of  severity  in  venereal  ulcers,  the  apparent  union  of  a 
chancroid  and  chancre  ("mixed  chancre"),  and  other  facts  of  clinical 
observation,  than  can  be  done  in  any  other  manner  we  know  of.  It  also 
explains  why  the  chancroid  has  been  known  among  all  nations  and  at  all 
times  of  which  we  have  any  record,  since  wherever  there  have  been  in- 
flammatory products  to  be  inoculated,  the7-e  the  chancroid  could  originate 
and  be  [)ei'petuated. 

The  only  vehicle  of  this  poison  is  the  secretion  of  the  ulcer  itself  and 
that  of  a  virulent  bubo  or  virulent  lymphitis  attendant  upon  it.  We  may 
go  further  and  assert  that  the  poison  does  not  exist  in  the  more  fluid  portion 
of  the  secretion,  but  in  the  contained  pus-globules,  since,  as  proved  by 
Rollet's  experiments,  if  chancroidal  jnis  be  freed  from  its  globules  by  filtra- 
tion, the  remaining  fluid  is  innocuous.  This  will  explain,  on  anatomical 
grounds,  why  the  chancroid  always  remains  local  in  its  action  and  never 
affects  the  general  system,  because  pus-globules,  as  such,  are  probably 
incapable  of  entering  the  general  circulation,  and  can  only  be  absorbed 
after  undergoing  disintegration.  AVe  shall  see,  further  on,  the  difference 
between  this  poison  and  that  of  syphilis,  which  latter  is  ibund  in  many  of 
the  fluids,  independently  of  the  presence  of  pus,  and  contaminates  the 
general  economy. 

An  important  characteristic  of  the  chancroidal  poison  is  the  facility  with 
which  it  may  be  reinoculated  upon  the  person  from  whom  it  was  taken,  or 
upon  almost  every  other  person.  This  rule,  however,  is  not  so  invariable 
as  Ricord  and  others  assert,  and  is  subject  to  exceptions  which  have  been 
brought  to  light  chiefly  by  Prof.  Boeck  and  other  advocates  of  "  syphiliza- 
tion." 

In  the  first  place,  the  susceptibility  varies  somewhat  in  different  per- 
sons, as  it  does  in  different  parts  of  the  body  in  the  same  person.  It  is 
not  true,  as  Ricord  once  stated,  that  "  all  persons  are  equal  before  the 
point  of  the  lancet." 

Again,  the  susceptibility  to  inoculation  may  be  impaired,  or  even  lost 
temporarily,  during  the  occurrence  of  any  acute  febrile  attack  or  great 
depression  of  the  vital  powers.  Thus,  in  several  of  our  former  cases  of 
"  syphilization"  at  Charity  Hospital,  an  intercurrent  attack  of  diarrhoea, 
oi' n  severe  cold,  und  in  one  instance,  of  variola,  rendered  attempts  at  inoc- 
ulation fruitless,  until  the  attack  had  passed  off. 

'  "It  is  easy,"  says  Dr.  Sanderson  (Lectures  on  Septicfemia),  "to  prepare  a 
putrid  infusion  of  muscle  possessing  such  toxic  properties  that  less  than  half  a 
yrain  oi  it  introduced  into  th-e  blood  of  a  dog,  will  produce  death." 


CHANCROIDAL    POISON.  341 

Farther,  if  a  series  of  successive  inoculations  be  marie,  the  resulting 
sores  will  gradually  become  smaller  and  smaller  until  they  become  so 
minute  as  not  to  afford  sufficient  matter  for  reinoculation,  or  they  fail  alto- 
gether. In  such  cases,  matter  may  still  for  a  time  be  inoculated  upon 
other  parts  of  the  body,  but  ultimately  the  patient  acquires  an  immunity 
against  the  action  of  the  poison.  The  same  effect  is  observed  after  the 
repeated  application  of  any  irritant,  as  croton  oil,  cantharides,  or  tartar 
emetic,  to  the  surface  of  the  body,  and  in  both  cases  there  is  reason  to 
believe  that  the  immunity  is  only  of  temporary  duration.  (See  Treatment 
of  Syphilis  by  Repeated  Inoculations.) 

Neither  the  microscope  nor  chemical  analysis  reveals  to  us  the  intimate 
nature  of  chancroidal  pus,  or  any  points  of  difference  between  it  and  pus 
from  ordinary  inflammation.  Several  enthusiasts,  at  different  times,  have 
imagined  that  they  had  discovered  a  parasite,  upon  which  the  virulence  of 
the  secretion  depends  ;  thus,  M.  Donne  regards  the  essential  principle  as 
the  vibrio  lineola,  M.  Didier  ascribes  it  to  certain  animalcuUe,  and  Prof. 
Salisbury,  of  Cleveland,  Ohio,  who,  by  the  way,  recognizes  no  distinction 
between  the  chancroidal  and  syphilitic  virus,  has  advanced  the  theory  of 
a  vegetable  parasite,  which  he  calls  crypta  syphilitica.  The  little  value 
to  be  attached  to  these  views  is  well  shown  in  a  paper  by  Prof.  Wood, 
published  in  the  American  Journal  of  the  Medical  Sciences  i'or  Oct.  1868, 
and  repeated  microscopical  examinations,  made  by  myself,  assisted  by  able 
microscopists,  at  Blackwell's  Island,  have  failed  to  show  any  foundation  for 
Prof.  Salisbury's  statements. 

When  kept  from  contact  with  the  air  at  a  moderate  temperature,  the 
chancroidal  poison  is  said  to  preserve  its  power  of  contagion  for  a  consid- 
erable length  of  time.  Ricord  states  that  he  has  inoculated  it  with  success 
after  preserving  it  in  glass  tubes  hermetically  sealed  for  seventeen  days. 
Sperino  relates  an  instance  of  its  preservation,  which,  however,  one  cannot 
help  doubting.  A  lancet  which  had  been  employed  in  artificial  inoculation 
had  been  laid  aside  for  seven  months,  when  it  was  observed  that  a  small 
quantity  of  dried  pus  had  been  left  upon  its  [)oint.  The  instrument  was 
moistened,  and  three  punctures  made  with  it  gave  rise  to  as  many  chancroids. 
If  exposed  to  a  high  degree  of  temperature,  or  if  mixed  with  alcohol,  an 
acid,  or  alkali,  the  chancroidal  poison  becomes  innocuous.  If  frozen  and 
then  thawed,  it  may  still  be  inoculated.  Dilution  with  from  six  to  ten  times 
its  quantity  of  water  does  not  destroy  its  {)otency  ;  but  it  is  said  that  if 
two  inoculations  be  made,  one  with  diluted  and  the  other  with  pure  matter, 
the  ulcer  produced  by  the  former  will  be  smaller,  although  just  as  persist- 
ent as  the  one  from  the  latter.'  M.  Puche  even  states  that  he  has  produced 
chancroids  by  inoculation  with  a  drop  of  pus  diluted  with  half  a  tumbler- 
ful of  water.  Mixture  with  any  of  the  normal  secretions  of  the  body,  or 
with  vaccine,  gonorrlHcal,  or  syphilitic  matter,  does  not  impair  its  power ; 
it  may  tlius  be  transmitted  in  tiie  process  of  vaccination,  and  its  comniuni- 

'  Redek,  Patholoyie  und  Theraplo  der  veuerischen  Krankheiten,   Wien,  1SG3, 
p.  142. 


342  CHANCROID. 

cation  in  common  with  the  syphilitic  virus  gives  rise  to  the  double  inocu- 
lation, improperly  called  a  ''  mixed  chancre." 

On  the  other  hand,  the  late  Prof.  Boeck^  emphatically  denied  the  ready 
preservation  of  chancroidal  matter,  and  stated  that  when  dried  it  almost 
always  lost  its  virulent  power,  which  could  only  be  preserved,  and  even 
then  merely  for  a  few  days,  by  keeping  it  fluid  and  hermetically  sealed 
from  contact  with  the  air.  Some  experiments  which  I  made  during  Prof. 
Boeck's  visit  to  New  York  seemed  to  confirm  this  statement.  I  allowed 
chancroidal  matter  to  dry  on  slips  of  glass,  and  after  the  lapse  of  twenty- 
four  hours  moistened  it  and  inoculated  it,  but  without  success  in  a  single 
instance. 

The  question  whether  the  chancroid  is  capable  of  transmission  to  the 
lower  animals,  has  attracted  the  attention  of  various  observers.  Hunter 
experimented  upon  dogs  and  asses,  and  arrived  at  the  conclusion  that  they 
were  not  susceptible  to  the  action  of  the  matter  Avhich  he  employed,  and 
which  must  have  been,  in  some  instances  at  least,  chancroidal.  M.  Ricord, 
in  his  notes  to  Hunter,  also  says:  "I  have  taken  pus  in  every  possible 
condition,  and  attempted  to  inoculate  with  it  dogs,  cats,  rabbits,  guinea- 
pigs,  and  pigeons ;  and,  in  no  case,  in  spite  of  the  variety  of  my  experi- 
ments, has  it  been  possible  to  communicate  the  disease."  More  recently, 
however,  successful  inoculations  of  chancroidal  matter  have  been  performed 
upon  a  number  of  the  lower  animals,  by  MM.  Auzias-Turenne,  Diday, 
Robert  de  Welz,  and  by  M.  Basset,  and  the  secretion  of  the  sores  thus 
produced  has  been  again  inoculated  upon  other  animals  and  upon  man. 
Thus  M.  Diday  inoculated  himself  upon  the  skin  of  the  penis  with  the 
secretion  of  a  chancroid  which  he  had  succeeded  in  developing  upon  the 
ear  of  a  cat  ;  the  inoculation  was  followed  by  a  chancroid  which  took  on 
phagedenic  action,  and  was  attended  by  a  bubo  in  the  groin  that  suppu- 
rated and  lasted  for  about  six  months. 

It  has  been  objected  to  these  experiments,  especially  by  M.  Cullerier, 
that  the  matter  was  simply  deposited  in  a  wound  made  in  the  integument 
of  the  animal,  and  was  thence  removed  and  successfully  inoculated,  with- 
out really  taking  effect  at  the  first  point  of  its  insertion.  M.  Cullerier 
says  :  "  I  shall  not  believe  in  a  true  inoculation  until  a  suppurating  sore 
has  been  produced  which  can  be  repeatedly  washed,  so  as  to  be  freed  from 
the  pus  which  produced  it,  and  which  yet  can  be  subsequently  reinoculated 
either  upon  the  animal  itself  or  upon  man."  We  are  assured,  however, 
that  these  precautions  were  taken  in  the  case  of  M.  Diday  and  his  cat,  and 
also  in  the  successful  inoculations  of  M.  Basset,  performed  in  1860;  and 
we,  therefore,  have  reason  to  believe  that  the  lower  animals  are  suscepti- 
ble to  the  action  of  the  chancroidal  poison,  though  probably  to  a  less  degree 
than  man.  Inoculations  with  the  true  syphilitic  virus  have,  on  the  con- 
trary, invariably  failed. 

'  Boeck  (Erfalirungen  iiber  Syphilis,  1875)  givos  a  large  number  of  experiments 
relative  to  the  preservation  and  inoculation  of  the  secretion  of  venereal  sores,  but 
liis  results  are  to  a  certain  extent  vitiated  by  the  fact  that  he  makes  no  distinction 
between  the  chancroid  and  the  true  chancre. 


CONTAGIOX.  343 

To  those  who  are  inclined  to  repeat  the  experiment  of  the  inoculation 
of  the  secretion  of  a  chancroid  upon  the  lower  animals,  I  would  say,  that 
success  is  not  likely  to  be  attained,  unless  a  wound  be  made  in  the  integu- 
ment, or,  better  still,  a  portion  of  the  derma  be  removed,  and  a  pledget  of 
lint  soaked  in  the  virus  be  bound  upon  the  part  for  twenty-four  to  Ibrty- 
eight  hours. 

An  eminent  syphilographer  of  Turin,  M.  Ricordi,  has  (18G8)  reported 
a  series  of  inoculations  upon  rabbits  with  tlie  secretions  both  from  the 
chancroid  and  the  true  chancre,  the  result  being  the  same  as  above  men- 
tioned, viz.,  success  with  the  former  and  failure  with  the  latter.'  In  one 
experiment  with  chancroidal  matter,  a  bubo  was  produced  tlie  pus  of 
which  was  inoculated  with  success  upon  a  second  rabbit.  Tliis  occur- 
rence of  a  virulent  bubo  in  the  lower  animals  has  not  been  before 
observed. 

Contagion, — Contagion  is  said  to  be  direct  or  mediate :  "  direct" 
when  the  matter  is  transferred  immediately  from  one  person  to  another  in 
the  act  of  coitus  or  other  intimate  mode  of  contact;  "mediate"  when 
some  foreign  substance,  itself  unaffected  by  the  virus,  serves  as  a  vehicle 
for  its  transmission.  An  attempt  has  been  made  by  certain  authors  to 
assign  different  laws  for  each  of  these  two  modes  of  contagion.  It  has 
been  said  that  the  act  of  coitus  involved  a  physiological  process,  or  a  state 
of  erethism,  which  rendered  the  conditions  and  the  effect  of  contagion  dis- 
tinct from  those  which  obtain  when  the  virus  is  communicated  by  an  inert 
and  senseless  body,  as,  for  instance,  the  point  of  a  lancet.  Such  a  dis- 
tinction is  wholly  unphilosophical  and  groundless,  and  deserves  to  be 
ranked  with  the  stories  of  Munchausen. 

In  whichever  mode  communicated,  certain  conditions  are  requisite  for 
tlie  poison  to  take  effect.  Its  a|)plication  to  the  sound  external  integument, 
hardened  by  exposure  and  friction,  is  as  innocuous  as  would  be  the  deposit 
of  vaccine  virus  upon  the  skin  without  previous  puncture.  The  surgeon 
frequently  soils  his  fingers  with  the  secretion  of  chancroids,  and  this  with 
impunity  so  long  as  their  stirliice  is  intact. 

Unless  it  gains  aecess  beneath  the  epidermis  or  epithelium,  its  effect  is 
null ;  but  as  soon  as  this  is  accomplished,  like  a  seed  it  begins  to  germi- 
nate, and  by  its  own  increase  and  multijdication,  and  by  the  ulceration  of 
the  surrounding  tissues,  a  chancroid  is  developed.  Hence  one  favorable 
condition  for  contagion  to  take  place  is  the  presence  of  an  abrasion,  as  is 
frequently  occasioned  by  violence  during  coitus,  and  through  which  the 
virus  may  penetrate,  I>ut  no  matter  how  the  solution  of  continuity  has 
been  produced,  nor  how  larger  or  minute  its  size — it  may  be  a  rent  or  tear, 
or  the  su[)erficlal  ulceration  underlying  a  herpetic  vesicle  ;  it  may  be  a 
chancre,  the  initial  lesion  of  syphilis,  or  a  secondary  symptom  like  a 
mucous  patch — it  affords  a  door  of  entrance  sufficient  tor  successful  inocu- 
lation.  , 

But  the  (piestion   naturally  arises  whether  this  law   is  absolute.      Is  it 

'  Ann.  univ.  di  mcd.,  Milano. 


344  CHANCROID. 

reasonable  to  suppose  that  in  all  of  t  lie  numerous  cases  of  simple  chancre,  some 
solution  of  continuity  must  have  existed,  without  which  contagion  could  not 
have  taken  place  ?  Is  it  not  possible  that  in  some  instances,  at  least,  the  virus 
may  have  permeated  the  external  layer  of  the  skin  or  mucous  membrane, 
without  any  denudation  of  the  epidermic  or  epithelial  layers?  I  am  not 
disposed  to  answer  tliis  (piestion  positively  in  the  negative  ;  it  is  one  which 
physiologists  are  better  entitled  to  solve  ;  yet  several  considerations  would 
lead  me  to  believe  that  there  is  no  necessity  of  explaining  on  the  theory 
of  endosmosis,  certain  cases  of  contagion  in  which  "no  solution  of  conti- 
nuity can  be  discovered.  The  epithelial  layer  of  the  mucous  membranes 
is  much  thinner  and  much  more  readily  removed  than  the  epidermis  of 
the  external  integument.  Continued  moisture,  as  is  seen  in  cases  of  an 
elongated  prepuce,  is  alone  sufficient  to  produce  a  superficially  excoriated 
surftxce  ;  the  effect  is  hastened  if  the  moisture  be  combined  with  purulent 
matter,  with  the  natural  sebaceous  secretion  of  the  ))art,  or  with  filth. 
The  door  of  entrance  may  be  merely  microscopic,  not  visible  to  the  naked 
eye ;  if  it  is  (?nly  large  enough  to  admit  a  single  pus  globule,  it  will  serve 
the  purpose  of  contagion.  It  would,  therefore,  seem  suflicient  to  sujjpose, 
with  Ricord,  in  cases  of  inoculation  without  ap[)arent  solution  of  conti- 
nuity, that  the  virulent  pus  has  at  first  acted  like  a  common  irritant,  until 
the  surface  had  become  denuded  at  some  minute  point,  which  would  enable 
it  to  exercise  its  power.  If  it  has  gained  entrance  within  the  open  mouth 
of  a  follicle,  the  same  eiFect  will  be  accomplished  the  more  readily. 

Instances  of  mediate  contagion  with  tlie  chancroidal  are  less  common 
than  with  the  sy})hilitic  virus.  Patients  occasionally  transfer  the  matter 
from  one  part  of  the  body  to  another  upon  their  fingers.  A  boy  at  present 
under  mv  care  with  chancroids  on  the  penis,  has  produced  a  similar  ulcer 
on  his  leg  by  scratcliing  a  pimple  in  that  situation.  After  tlie  operation 
for  })himosis  in  our  venereal  hospitals,  the  wound  is  not  unfrerpiently 
inoculated  by  the  use  of  cutting  instruments,  serres-fines,  sponges  or  towels, 
smeared  with  chancroidal  pus.  Fournier  states  that  one  of  his  patients 
contracted  a  chancroid  upon  his  finger  by  washing  his  hands  in  water 
which  had  been  v.sed  a  few  moments  before  by  a  friend  for  the  purpose  of 
cleansing  his  j)enis  which  was  affected  with  chancroids.  The  seats  of 
Avater-closets  may  unquestionably  serve  as  the  medium  of  contagion, 
althougli  not  to  the  extent  that  is  alleged  by  patients,  the  frequency  of 
whose  assertion  to  this  effect  has  led  to  the  remai'k  that  "  only  clergymen 
contract  venereal  diseases  in  that  way." 

It  has  occasionally  been  noticed  that  a  man  would  contract  a  chancroid 
from  a  woman,  who,  upon  examination,  was  found  to  have  nothing  the 
matter  with  her,  but  who  was  discovered  to  have  had  intercourse  a  short 
time  previously  witli  sonu;  man  who  had  this  disease  ;  and  the  question 
has  arisen  whether  (;liancroidal  pus  might  not  be  deposited  by  one  man  in 
the  vagina,  to  be  picked  up  by  another  without  the  woman  herself  being 
affected;  her  genital  organs  thus  serving  merely  as  the  medium  of  con- 
tagion. Thus  Ricord  rejmrts  a  case  in  which  a  married  pair  invited  a 
friend,  an  officer,  to  dinner.      Everything  went  on  in  an  unexceptionable 


COXTAGIOX.  345 

manner  till  near  the  close  of  the  repast,  when  it  was  discovered  that  there 
was  no  cheese  in  the  house,  and  the  husband  w.ent  out  to  purchase  some. 
The  officer  took  advantage  of"  his  absence  and  abused  the  rights  of  hospi- 
tality. A  few  days  after  the  husband  broke  out  with  a  chancroid,  and 
applied  to  Ricord  for  advice.  Ricord  examined  the  wife  and  found  her 
free  from  disease,  but  obtained  a  confession  of  her  exposure  with  the  officer, 
who  liappened  at  the  same  time  to  be  under  Ricord's  treatment  for  chan- 
croids. 

To  test  tlie  possibility  of  such  an  occurrence,  M.  Cullerier  instituted  the 
following  experiment: — 

Louise  Yaudet  entered  the  Lourcine  Hospital  Oct.  10,  1848,  to  be 
treated  for  an  ulcer  of  grayish  aspect  and  witli  shar|)ly  cut  edges  in  each 
groin,  whicli  had  already  persisted  without  treatment  for  a  month.  There 
was  considerable  surrounding  inflammation,  which  was  subdued  by  rest 
and  poultices,  when  the  genital  organs  and  anus  were  carefully  examined 
and  found  to  be  free  from  ulceration.  The  vagina  was  reddened  and 
smeared  with  an  abundant  muco-purulent  secretion,  but  its  mucous  sur- 
face was  intact  and  the  os  uteri  healthy.  The  inguinal  ulcers  were 
dressed  with  charpie  moistened  in  aromatic  wine,  and  vaginal  injections  of 
a  solution  of  alum  ordered;  under  which  treatment  the  sores  and  vaginitis 
rapidly  improved. 

Nov.  2o,  after  finding  on  a  second  examination  that  the  mucous  mem- 
brane of  the  vulva  and  vagina  was,  as  befoi-e,  intact,  and  after  inoculating 
without  success  the  vaginal  secretion,  M.  Cullerier  collected  upon  a  spatula 
a  consideiable  quantity  of  pus  from  the  ulcers  in  the  groins  and  deposited 
it  in  the  vagina.  The  patient  was  then  directed  to  walk  about  under  sur- 
veillance lest  she  should  touch  the  parts,  and  at  the  end  of  thirty-five 
minutes  was  again  placed  upon  the  bed,  and  some  of  the  fiuid  found  in  the 
vagina  was  inoculated  upon  her  thigh.  The  vagina  and  vulva  were  then 
freely  washed  with  water,  dried,  and  waslied  a  second  time  with  a  solution 
of  alum.  Two  days  after,  the  inoculation  had  produced  the  characteristic 
pustule  of  a  chancroid,  which  was  left  another  twenty-four  hours  to  confirm 
the  diagnosis,  and  then  destroyed  with  Vienna  paste.  Repeated  subse- 
quent examination  showed  that  no  ulceration  had  been  caused  in  the 
vagina,  whicii  was  not  even  more  infiamed  than  before.  In  two  months 
the  patient  left  the  hospital  cured  of  both  her  vaginitis  and  inguinal  ulcers. 

In  a  second  case  in  which  this  experiment  was  performed,  the  pus 
was  allowed  to  remain  in  the  vagina  for  nearly  an  iiour  and  did  not  take 
f'ffect.' 

Tarnowski'^  has  repeated  these  experiments  in  a  numl)er  of  instances 
with  the  same  result. 

It  would  thus  ajjpear  that  in  rare  instances  the  .sound  vagina  may  play 
the  part  of  a  niere  niedium  of  contagion,  and  the  same  may  possibly  be 
true  of  the  genital  organ  of  the  male. 

According  to  Auspitz,"'  who  cites  iiis  autliorities,  mediate  contagion  was 

'  Quclques  points  do  hi  contagion  mediate    M6n\.  Soc.  de  chir.  do  I'iiris,  ciuoted 
in  Lemons  sur  le  diancre,  p.  255. 
«  Voitrii<,'e,  p.  55. 
'  Die  Lehren  vora  syph.  Cojitagium,  p.  89. 


346  CHANCROID. 

known  to  Widemann,  Vella,   Fernel,   Thierry  de  Hery  jind  Ambrosius 
Pare,  de  Blegny,  Astrue  and  Swediaur. 

Frequency  of  the  Chancroid — Of  the  three  venereal  diseases, 
gonorrhtjea  is  undoubtedly  by  far  the  most  frequent,  as  shown  by  the  expe- 
rience of  every  surgeon,  and  numerous  cases  of  this  disease  are  treated  by 
l)atients  themselves  who  never  appear  for  advice  or  consultation. 

The  frequency  of  the  chancroid  as  compared  with  that  of  the  true  cliancre 
is  not  so  readily  determined  ;  indeed  we  have  reason  to  believe  that  it  has 
varied  at  different  periods,  and  we  know  that  it  varies  in  different  classes 
of  society. 

At  the  time  when  a  distinction  between  the  cliancroid  and  chancre  first 
began  to  be  recognized,  it  was  the  universal  testimony  that  the  former  was 
much  more  frequently  met  vvith  tlian  the  latter. 

Bassereau's  notes  of  patients  presenting  themselves  at  M.  Ricord's  clin- 
ique  in  1837  and  1838  would  even  show  the  immense  disproportion  of 
thirty  chancroids  to  one  true  chancre,  which  is  almost  incredible,  but  the 
former  must  at  any  rate  have  been  greatly  in  the  majority.' 

M.  Puche  prepared  a  table  of  all  the  venereal  ulcers  resulting  directly 
from  contagion  which  entered  the  H6i)ital  du  Midi  during  ten  years  (1840 
-1850)  and  formed  a  total  of  10,300,  of  which  804o  were  chancroids  and 
195;")  chancres;'*  in  other  words,  the  ratio  of  the  former  to  the  latter  was 
nearly  as  4  to  1.  The  statistics  of  other  observers  represented  the  ratio  as 
somewhat  less,  as,  for  instance,  3  to  1  or  2  to  1  ;  but  all  concurred  in  show- 
ing the  decidedly  greater  frequency  of  the  chancroid  especially  when  the 
observations  were  made  in  hospitals  frequented  by  the  lower  classes  of 
society. 

Now,  taking  this  very  same  hospital,  the  Hopital  du  Midi,  in  18G9  and 
1870,  Mauriac  (op.  cit.)  observed  the  curious  fact  that  these  figures  were, 
almost  reversed ;  the  chancroid  was  in  the  minority ;  and  it  bore  the  ratio 
of  1  : 1.8  to  the  true  chancre  ;  in  other  words,  there  were  nearly  tivo  chan- 
cres to  every  chancroid. 

But  observe  what  took  place  in  the  same  hospital  in  1870-1  during  the 
war  with  the  Germans  and  the  siege  of  Paris.  Statistics  at  such  a  time 
were,  as  might  be  supposed,  less  perfectly  kept,  but  they  were  sufficient  to 
show  that  in  1870  the  chancroid  was  to  the  true  chancre  in  the  ratio  of 
two  to  one,  and  in  1871  in  the  ratio  of  three  to  one,  thus  reversing  again 
the  tables  of  their  comparative  frequency.  Mauriac  says :  "  After  the 
reign  of  the  Commune,  our  wards,  which  had  been  occupied  during  the 
siege  by  the  wounded,  were  filled  with  venereal  patients,  and  tlie  greater 
part  of  them  with  simple  chancres"  (chancroids). 

In  the  years  succeeding  the  Franco-German  war,  the  ratio  of  tlie  chan- 
croid once  more  gradually  diminished  until  in  1874  it  reached  the  lowest 

'  Rarete  actuelle  du  chancre  simple,  par  Chas.  Mauriac,  MeJecin  de  I'hOijital  du 
Midi,  Paris,  1876,  p.  17. 

*  FouKNiEK,  Le(jf)us  sur  le  chancre,  p.  15. 


FREQUENCY    OF    THE    CHANCROID  347 

iigure  it  lias  ever  been  known  to  attain,  and  \vas,  compared  with  tlie  true 
cliancre,  as  one  to  six  and  four-tentlis ;  in  other  words,  there  was  only  one 
chancroid  to  six  chancres  recorded  on  the  Register  of  the  H6|)ital  du 
Midi  during  that  year.  In  the  following  year,  it  was  a  little  more,  viz.,  one 
to  five. 

Doubtless  some  errors  crejjt  into  the  above  statistics,  but  making  every 
reasonable  allowance  for  the  same,  they  unquestionably  show  a  gradual 
decrease  of  chancroidal  ulcers  in  compai'ison  with  true  chancres.  It  should 
be  stated  that  Mauriac's  statistics  are  confirmed  by  those  from  other  large 
cities,  as  Lyons.  I  have  no  accurate  statistics  of  my  own  to  offer,  but  I 
cannot  be  mistaken  in  asserting  that  I  meet  with  the  chancroid  much  less 
frequently  than  I  did  twenty-seven  years  ago,  when  I  was  commencing 
practice. 

To  what  is  this  gradual  decrease  in  the  frequency  of  the  chancroid 
owing?  It  is  impossible,  I  think,  to  give  a  perfectly  satisfactory  reason. 
Mauriac,  who  believes  in  the  existence  of  a  specific  chancroidal  virus, 
ascribes  it  to  the  gradual  extinction  of  this  virus  in  consequence  partly  of 
the  police  regulations  controlling  prostitution  in  Paris,  and  partly  owing  to 
the  fact  that  a  chancroid  rarely  escapes  observation,  and,  once  cured,  does 
not  reappear ;  whilst,  on  the  contrary,  syphilitic  lesions  are  less  likely  to 
attract  the  notice  of  the  patient,  and  are  of  constant  recurrence.  It  is 
hardly  necessary  to  state  that  the  increase  of  chancroids  during  the  siege 
of  Paris  is  more  readily  explainable  on  the  ground  of  the  great  laxity  of 
morals  and  the  inattention  to  cleanliness  that  prevailed  at  that  time. 

Again,  the  comparative  frequency  of  the  simple  and  syphilitic  chancre 
depends  in  a  measure  upon  the  position  in  the  social  scale  to  which  patients 
belong,  since,  as  shown  by  the  observations  of  MM.  Martin  and  Belhomme,^ 
and  those  of  M.  Fournier,^  in  the  better  classes  of  society  the  chancre  is 
much  more  frequent  than  the  chancroid.  M.  Fournier  says:  "  In  private 
practice  tlie  simple  cliancre  is  rarer  than  the  syphilitic  chancre.  I  have 
been  especially  struck  with  this  difference,  which  may  be  expressed  in 
figures  as  follows  : — 

Simple  chancres  ........        82 

Syphilitic  chancres     ........     252 

"  Thus  it  is  a  curious  fact  which  may  have  some  interest  in  a  prophy- 
lactic point  of  view,  that  the  simple  chancre,  which  is  common  in  the  lower 
classes,  becomes  rarer  and  rarer,  relatively  to  the  syphilitic  chancre,  in 
proportion  as  we  rise  in  the  social  scale."  M.  F'ournier  would  explain  this 
fact,  on  the  ground  that  men  of  the  lower  classes  most  frequently  contract 
venereal  diseases  from  old  prostitutes  who  are  already  protected  by  one 
attack  of  syphilis  from  another,  but  who  are  still  subject  to  chancroids ; 
while  the  women  who  are  sought  after  by  the  higher  classes  are  commonly 
younger 'und  fresher,  and  hence  more  likely  to  be  affected  Avith  true  chan- 

'  Trait6  de  pathologie  syph.  at  v6n.,  p.  127. 

*  N.  Diet,  de  med.  et  de  chir.  prat.,  Paris,  t.  vii,  p.  67. 


348  CHANCROID. 

ores  or  secondary  symptoms,  and  to  convey  syphilis  to  those  with  whom 
they  have  connection.  The  different  habits  of  the  upper  and  lower  classes 
of  society  must  also  have  an  influence. 

Seat  of  the  Ciianckoid TJie  chancroid   is  most  frequently  seated 

in  the  neighborhood  of  the  genital  organs,  simply  because  these  parts  are 
most  exposed  to  contagion  and  not  in  conse(iuence  of  any  peculiar  aptitude 
which  they  possess.  If  chancroidal  matter  be  inserted  beneath  the  epi- 
dermis of  any  other  part  of  the  body,  a  chancroid  is  equally  the  result. 
Nor  is  this  the  limit  to  its  seat ;  it  is  also  found  within  various  mucous 
canals — as  the  urethra,  vagina,  and  rectum — opening  upon  the  surface,  at 
as  great  a  depth  as  these  passages  can  be  explored  by  the  senses  during 
life,  and  post-mortem  examinations  have  been  supposed  to  prove  the  possi- 
bility of  its  presence  in  the  bladder,  though  such  instances  are  questionable. 
The  whole  external  integument,  and  whatever  portions  of  the  mucous 
membranes  are  accessible  to  the  im|)Iantation  of  the  poison,  are  therefore 
exposed  to  become  its  seat.  The  frequency  with  which  it  is  met  elsewhere 
than  upon  the  genitals,  depends  in  a  great  measure  upon  the  habits  and 
cleanliness  of  persons  exposed  to  contagion. 

The  most  reliable  statistics  as  to  the  seat  of  the  chancroid,  in  the  two 
sexes,  are  those  of  Fournier^  and  Debauge,^  the  former  conlining  his  ob- 
servations to  men,  the  latter  to  women. 

I.  fourniek's  table  (men). 

Cliancroids  of  the  glans  or  prepuce         ......  347 

"  on  the  sheath  of  the  penis    ......  21 

"  on  various  parts  of  the  penis,  as,  for  instance,  occupying 

the  prepuce  and  sheath,  the  sheath  and  the  glans,  etc.  24 

"  on  the  penis  (exact  situation  not  recorded)            .         .  25 

"  "      meatus       ........  11       • 

"  within  the  urethra        .......  5 

"  of  tlie  scrotum      ........  3 

"  on  the  pubes          ........  3 

'•  "      fingers         ........  2 

"  "      upper  and  inner  portions  of  the  thiglis      .         .  2 

"  of  the  anus            ........  1 

"  "      anterior  thoracic  region       .....  1 

Total         .         .         .445 


'  N.  Diet,  de  med.  et  de  chir.  prat.,  Paris,  t.  vii,  p.  72. 

2  These  de  Paris,  1838,  jj.  62.    Statistics  collected  in  the  service  of  M.  Bonnarie, 
at  the  Hospice  de  I'Antiquaille,  Lyons. 


SEAT    OF    THE    CHANCROID.  349 

II.  debaloe's  table  (women). 

Chancroids  on  tlie  fourchette  or  fossa  navicalaris             ...  78 

"                "      labia  majora       .         .         .          .         .         .         .  19 

"                "         "     minora       .          .         .         .          .          .          .  16 

"          of  the  meatus  (of  these  19  extended  within  the  urethra)  21 

"           in  the  neighborhood  of  the  meatus        ....  2 

"          of  the  vestibule    ........  4 

"  "      clitoris         .         .         .         .         .         .         .         .1 

"  at  the  entrance  of  the  vagina   (just  external  to  the 

carunculse,  and  between  the  carunculse  and  the  labia 

minora)               ........  17 

"           of  the  vagina,  behind  the  carunculae    ....  7 

"                "       uterine  neck       .          .         .          .          .         .          .  1 

"                "      margin  of  the  anus    ......  23 

"           in  the  groove  between  the  nates    .....  5 

"           of  the  perinseuni             .......  5 

"          on  the  internal  surface  of  the  thighs    ....  5 

"                "      hypogastrium     .......  2 

Total         .         .         .206 

1)1  reviewing  these  tables,  it  is  worthy  of"  observation  how  large  a 
majority  of  chancroids  are  genital  and  "peri-genital,"  or  those  situated 
upon  or  in  the  neighborliood  of  tlie  genital  organs  in  both  sexes;  indeed 
"extra-genital"  chancroids,  or  those  at  a  distance  from  the  genitals,  are 
mentioned  only  as  rare  exceptions.  As  we  shall  see  hereafter,  there  is  a 
marked  difference  in  this  respect  between  the  chancroid  and  the  true 
chancre,  the  latter  being  found  in  a  much  larger  proportion  upon  distant 
parts  of  the  body.  This  difference  is  accounted  for  by  the  fact  that  the 
chancroid  is  transmitted  almost  exclusively  in  sexual  intercourse,  while 
the  initial  lesion  of  syphilis,  arising  as  it  may  from  either  a  primary  or  a 
secondary  lesion,  finds  many  other  modes  of  origin  than  the  mere  act  of 
coitus. 

Tiie  chancroid  is  said  not  to  be  confined  to  tlie  normal  tissues  of  the 
body,  but  also  to  affect  pathological  growths.  In  a  case  related  by  Prof. 
Breslau.  of  Zurich,  "a  simple  chancre  was  developed  upon  a  mass  of 
epithelial  cancer  attached  to  the  cervix  uteri,  and  the  virulent  nature  of 
the  sore  was  demonstrated  by  the  successful  inoculation  of  the  pus  upon 
the  patient's  thigh."  This  case  must,  however,  be  received  with  some 
reserve,  now  that  we  know  that  the  secretion  of  lesions  other  than  clian- 
croidal  may  sometimes  be  auto-inoculated. 

A  singular  exception  to  the  rule  tliat  all  portions  of  the  body  are  equally 
prone  to  contract  a  chancroid  has  been  noticed,  viz.,  that  this  ulcer  is 
rarely  met  with  in  practice  upon  the  head,  face,  or  buccal  cavity,  where, 
on  the  contrary,  the  initial  lesion  of  syphilis  is  not  uncommon.  At  one 
time  this  fact  excited  no  little  discussion,  since  it  was  supposed  to  conflict 
with  the  distinct  nature  of  the  chancroid  and  syphilis,  and  to  favor  the 
idea  that  the  seat  of  the  contagion  exerted  an  influence  either  for  or  against 
contamination  of  the  general  system,  and  hence  that  the  chancroidal  and 
syphilitic  poisons  were  one. 


350  CHANCROID. 

The  important  bearing  of  this  question  led  to  an  extensive  investigation 
for  the  purpose  of  ascertaining  if  the  alleged  exemption  was  founded  on 
fact.  Fournier^  took  a  prominent  part  in  this  labor,  and,  from  a  diligent 
search  through  medical  works,  and  inquiry  of  those  who  made  a  special  study 
of  venereal  diseases,  was  able  to  collect  150  cases  of  venereal  ulcers  upon 
the  head  and  face,  all  of  which,  however,  with  the  exception  of  o,  were 
chancres.  These  five  exceptional  cases,  in  which  the  ulcer  was  supposed 
to  be  a  chancroid,  had  been  observed  by  MM.  Ricord,  Venot,  Devergie, 
Bassereau,  and  Diday ;  but  Ricord  confessed  that  his  case,  an  ulceration 
at  the  base  of  one  of  the  superior  incisor  teeth  (figured  in  his  Icono- 
grapliie,  pi.  21),  was  unreliable,  and  the  other  four  were  thought  to  be 
imperfectly  reported  ;  and  thus  there  could  remain  no  doubt  of  the  rarity 
of  the  chancroid  upon  the  region  in  question. 

It  has  been  since  ascertained  that  the  chancroid  can  be  developed  upon 
the  head  and  face  by  artificial  inoculation.  Puche'*  and  Rollei^  liave  in- 
oculated its  virus  with  success  u[)on  diflerent  parts  of  the  head  in  20 
instances;  Bassereau*  and  Prof.  Huebbenet,"  of  Kieff,  upon  the  lips  and 
cheeks  in  five ;  Robert®  upon  the  temple,  nose,  and  lips  in  three,  and  in 
all  tlie  sore  so  produced  was  entirely  free  from  induration,  and  was  not 
followed  by  secondary  symptoms — a  fact  which  utterly  demolishes  the 
argument  of  the  "  unitists."' 

Still  farther,  at  least  two  instances  of  the  occurrence  of  chancroids  upon 
the  cephalic  region  have  been  met  with  in  clinical  experience,  in  which 
every  precaution  appears  to  have  been  taken  to  establish  the  diagnosis. 
The  first  is  reported  by  Fournier  himself,  from  the  notes  of  M.  Puche,  of 
the  Hopital  du  Midi  ;  the  sore  was  situated  upon  the  lower  lip,  and  artifi- 
cial inoculation  of  its  secretion  upon  the  patient's  abdomen,  as  well  as  an 
accidental  inoculation  upon  the  patient's  thumb,  proved  successful ;  no 
general  symptoms  showed  themselves  within  seventy-four  days  from  the 
appearance  of  the  ulcer,  during  which  period  the  patient  was  kept  under 
observation,^  In  the  second  case,  observed  by  M.  Rofeta,'  at  Palermo,  a 
serpiginous  chancroid,  of  two  years'  duration,  was  situated  upon  the  face, 
and  its  secretion  was  inoculated  in  five  places  by  M.  R.  upon  himself,  with 

'  Etude  sur  le  chancre  cephalique,  Union  med.,  Paris,  fev.  et  mars,  1858. 

2  Nadau  des  Islets,  De  I'inoculation  du  cliancrc  iiiou  h  la  region  cephalique, 
These  de  Paris,  1858. 

3  Gaz.  Med.  de  Lyon,  Dec,  1857. 

*  BuzENET,  Du  chancre  de  la  bouche,  Th6se  de  Paris,  1858,  p.  41. 

5  Union  med.,  Paris,  20  mat,  1858. 

6  Nouveau  traite  des  mal.  veiieriennes,  Paris,  18(;i,  p.  380. 

7  Robert's  reply  to  this,  that  a  chancroid  may  be  forced  upon  the  tissues  of  the 
head  and  face  by  artificial  inoculation,  but  that  the  same  tissues  will  develop  a 
syphilitic  ulcer  even  from  the  chancroidal  virus,  when  contaminated  in  coitu,  ap- 
pears to  me  weak  and  puerile.  What  possible  difference  upon  the  development 
of  the  sore  can  it  make  whether  the  virus  is  deposited  by  the  surgeon's  lancet  or 
by  the  penis  in  connection  ub  ore? 

8  N.  diet,  de  med.  et  de  chir.  prat.,  Paris,  t.  vii,  p.  7(i. 

9  Gaz.  ui6d  de  Lyon,  9  juin,  18(57,  p.  275. 


CHANCROID    FROM    INOCULATION.  351 

the  effect  of  producing  five  chancroids,  which  have  not  been  followed  by 
any  symptoms  of  syphilis  during  eighteen  months  tliat  have  since  elapsed. 
I  shall  content  myself  with  this  brief  sketch  of  the  discussion  relative 
to  the  "  cephalic  chancre,"  which  for  a  time  attracted  no  little  attention, 
but  which  assumes  less  importance  now  that  it  is  known  not  to  conflict 
with  a  duality  of  poisons.  Its  only  practical  bearing  is  this  :  that  the 
rarity  of  the  chancroid  upon  the  head  and  face,  furnishes  strong  ground 
of  belief  that  any  venereal  ulcer  met  with  upon  this  region  is  syphilitic. 

The  Chancroid  fro-M  Inoculation — Thanks  to  the  ease  with  which 
the  chancroid  may  be  inoculated  upon  the  person  bearing  it  and  the  safety 
with  which  this  operation  may  be  performed,  we  have  the  rare  opportunity 
of  developing  this  disease  at  pleasure,  and  watching  its  progress  from  its 
very  commencement.  We  may  plant  the  seed  and  observe  its  growth, 
and  tlius  obtain  a  knowledge  of  its  natural  history,  which  we  may  after- 
wards compare  with  the  various  stages  and  varieties  met  with  in  practice. 

Artificial  inoculation  is  usually  performed  upon  the  person  from  whom 
the  matter  is  taken,  and  is  then  called  auto-inoculation  ;  when  practised 
upon  another  [)erson  it  is  called  hetero-inoculation. 

How  is  the  operation  performed  ?  Some  portion  of  the  external  integu- 
ment should  be  selected  which  is  sufficiently  open  to  observation,  and 
where,  if  the  inoculation  prove  successful,  the  sore  is  least  likely  to  attain 
a  considerable  size,  or  to  affect  the  neighboring  ganglia  in  case  its  early 
cauterization,  as  soon  as  the  purpose  of  the  inoculation  has  been  accom- 
plished, should  fail  to  destroy  it. 

The  experiments  of  the  advocates  of  syphilization  show  that  the  sides 
of  the  chest,  below  the  nipples,  best  fulfil  these  indications.  In  this  situa- 
tion chancroids  rarely  attain  a  large  size,  and  the  axillary  ganglia  are  too 
far  removed  to  be  readily  affected. 

M.  Clerc  recommends  an  ordinary  pin  as  the  preferable  instrument  to 
be  employed,  for  the  following  reasons  :  it  is  always  at  hand  and  may 
always  be  had  clean  ;  it  is  not  formidable  to  the  patient ;  it  is  not  likely 
to  make  a  deep  wound,  and  we  find  that  a  sujierficial  insertion  of  the  virus 
affords  greater  security  against  large  and  troublesome  sores. 

But  for  convenience  no  instrument  is  better  than  the  common  lancet ; 
only  be  certain  of  its  cleanliness.  Moisten  its  tip  with  the  purulent  secre- 
tion, and  place  the  point  iierpendicularly  upon  the  spot  you  wish  to  inoculate  ; 
with  a  slight  impulse  the  point  is  made  to  penetrate  to  the  derma ;  the 
instrument  is  turned  once  round  on  its  axis  and  withdrawn  ;  any  remains 
of  the  pus  upon  the  instrument  is  smeared  over  the  orifice  of  the  puncture, 
and  tlie  operation  is  com[)leted  in  less  time  than  it  has  taken  to  describe 
it.     No  after- care  is  required. 

The  evidence  of  a  successful  inoculation  is  usually  apparent  on  the  fol- 
lowing day  ;  sometimes  not  until  after  the  lapse  of  two,  three,  or  even  four 
days.  The  point  inoculated  is  of  course  reddened  from  the  outset  ;  if  the 
inoculation  "  takes,"  a  pustule,  surrounded  by  an  inflammatory  areola, 
appears  within  the  time  just  mentioned,  and  on  removing  the  epidermis 


352  CHANCROID. 

an  nicer  is  found,  penetrating  the  whole  thickness  of  the  skin,  its  edges 
abrupt,  jagged,  and  undermined  ;  its  outline  circular;  its  floor  of  a  gray- 
ish color,  and  presenting  slight  elevations  and  depressions,  best  seen 
through  a  magnifying  glass. 

If,  on  the  other  hand,  the  pustule  be  left  unbroken,  the  contained  matter 
concretes  and  forms  a  scab  of  conical  form,  whicii  increases  by  additions 
to  its  circumference  and  covers  the  ulcer  beneath,  which  is  being  further 
developed. 

The  tendency  of  this  ulcer  is  to  extend,  at  first  rapidly,  and  afterwards 
more  slowly,  for  several  weeks ;  then  comes  a  period  during  which  no 
increase  is  perceptible,  and  the  sore  appears  stationary  ;  and  finally  the 
process  of  repair  is  set  up,  usually  commencing  at  the  circumference,  and 
the  ulcer  closes,  leaving  a  cicatrix  which  is  more  or  less  permanent  accord- 
ing to  the  depth  and  extent  of  the  preceding  ulceration. 

As  soon  as  all  doubts  are  removed,  the  sore  should  be  destroyed,  by  first 
removing  its  secretion  and  then  applying  a  strong  caustic,  as  the  carbo- 
sulphuric  paste,  or  fuming  nitric  acid. 

From  this  experiment,  which  has  been  performed  in  many  thousand 
instances  with  the  same  result,  we  are  justified  in  inferring: — 

1.  That  the  chancroid  has  no  period  of  incul)ation;  that  the  pathological 
process  is  set  up  the  moment  the  poison  is  introduced  beneath  the  epidermis. 

2.  That  the  chancroid  first  appears  as  a  pustule,  but  that  it  essentially 
consists  in  an  ulcer  underlying  the  elevated  epidermis,  and  presenting  the 
characteristics  above  stated. 

3.  That  the  course  of  a  chancroid  may  be  divided  into  three  stages:  the 
progressive,  stationary,  and  reparative. 

4.  That  the  chancroid  is  capable  of  healing  spontaneously,  without  the 
intervention  of  art. 

We  shall  presently  see  how  far  these  conclusions  are  confirmed  by  cases 
met  with  in  practice.  There  should  be  no  marked  difference,  since  the 
circumstances  attending  the  inoculation  and  contagion  are  the  same,  except 
that  in  the  former  we  take  care  to  remove  all  disturbing  influences,  and 
leave  the  disease  to  pursue  its  regular  course. 

The  Chancroid  from  Contagion — Development — The  first  point 
that  claims  our  attention  is  the  time  of  development  of  the  chancroid  after 
exposure  ;  in  other  words,  is  there  an  absence  of  a  period  of  incubation 
with  the  chancroid  from  contagion,  as  we  have  found  to  be  true  of  the 
chancroid  from  inoculation  ?  This  question  becomes  more  complex  as 
soon  as  we  turn  to  cases  met  with  in  practice;  since  patients  have  often 
had  several  recent  connections,  and  we  cannot  tell  with  certainty  which 
was  really  the  infecting  one.  Even  if  there  has  been  but  one  exposure 
after  a  long  period  of  continence,  we  are  still  obliged  to  rely  u[)on  the  state- 
ments of  unprofessional  persons,  often  careless  in  their  habits,  in  our  at- 
tempts to  ascertain  the  exact  time  of  the  appearance  of  the  sore.  Their 
testimony  can  include  only  what  they  themselves  have  observed,  and  not 
necessarily  what  has  actually  taken  place.     The  chances  are  that  many  of 


CHANCROID    FROM    CONTAGION.  353 

them  will  post-date  the  appearance  of  the  ulcer,  which  was  entirely  unex- 
pected, and  consequently  not  observed  at  its  commencement. 

Yet  with  this  liability  to  error,  we  find  in  the  main  that  the  testimony  of 
patients  confirms  the  results  of  artificial  inoculation,  and  that  they  repre- 
sent the  time  after  exposure  when  their  ulcers  had  attained  sufficient  size 
to  attract  their  attention  as  having  been  but  a  few  days.  Thus,  in  fifty- 
two  cases  in  which  there  had  been  only  a  single  connection  for  along  period 
(three  to  five  months  or  more),  Fournier  found  that  the  patients  assigned 
the  date  when  they  first  noticed  their  chancroids  as  follows  : — 

Casks. 

The  first  day  after  exposure 6 

The  second  day  after  exposure    .......  2 

The  third  day  after  exposure       .......  9 

From  the  third  to  the  fourth  day         ......  4 

The  fourth  day 3 

The  fifth  day  1 

The  sixth  day 3 

From  the  seventh  to  the  eighth  day     ......  13 

The  ninth  day     ..........  1 

The  tenth  day 2 

The  eleventh  day         .........  1 

The  thirteenth  day 2 

From  the  thirteenth  to  the  fourteenth  .....  3 

From  the  seventeenth  to  the  twentieth         .....  2 

Total 52 

It  appears  from  this  table  that  the  existence  of  the  chancroid  was  recog- 
nized by  the  patient  in  24  cases,  from  the  first  to  the  fourth  day  ;  in  17  cases, 
from  the  fourth  to  the  eighth  day;  and  in  11  cases  after  the  eiglith  day  ; 
hence  that  in  41  cases  out  of  52,  or  in  about  4  cases  out  of  5,  it  was  seen 
during  the  first  week,  and  in  only  11  cases  at  a  later  period. 

With  regard  to  these  eleven  exceptional  cases,  Fournier  also  states  that 
the  sore,  at  the  time  it  was  discovered,  presented  such  a  degree  of  devel- 
opment as  to  show  that  it  had  already  existed  for  a  number  of  days,  ranging 
probably  from  five  to  twelve. 

Taking  into  consideration  the  inadvertence  and  the  incapacity  of  patients 
as  observers,  we  are  therefore  justified  in  concluding  that  there  is  the  same 
absence  of  incubation  with  the  chancroid  from  contagion  that  we  know  to 
exist  with  the  chancroid  from  inoculation.  And  as  stated  by  Ricord, 
there  is  still  another  circumstance  to  be  taken  into  account ;  when  the  virus 
is  deposited  upon  the  sound  integument  or  mucous  membrane,  it  cannot 
immediately  take  effect ;  it  has  first  to  act  as  a  common  irritant,  eroding 
the  surface  and  destroying  the  epidermis  or  epithelium;  and  only  wlien  this 
is  accomplished  can  it  exercise  its  specific  action.  But  this  preparatory 
work  recpiires  time,  and  by  so  much  delays  the  appearance  of  the  ulcer. 
In  this  manner  we  can  readily  explain  the  rare  instances  in  which  the  evo- 
lution of  a  chancroid  has  taken  place  after  an  interval  of  several  days 
following  exposure.  In  point  of  fact,  it  has  no  period  of  incubation,  whether 
produced  by  contagion  or  inoculation. 
23 


354  CHANCROID. 

As  we  shall  see  hereafter,  this  constitutes  one  important  means  of  diag- 
nosis between  the  chancroid  and  the  true  chancre. 

In  practice  we  do  not  often  see  the  initial  pustule  of  the  chancroid, 
which  has  usually  been  ruptured  before  the  patient  comes  under  observa- 
tion, or  the  virus  may  have  inoculated  some  previous  solution  of  continuity; 
and  in  such  cases  we  find  at  the  outset  either  a  scab  formed  by  concreted 
pus  when  the  ulcer  is  situated  upon  the  external  integument,  or  an  open 
sore  when  it  occupies  some  moist  surface,  as  the  balano-preputial  fold  or 
the  mucous  membrane  of  the  vulva.  A  rent  or  abrasion  is  not  necessarily 
inoculated  at  once  to  its  full  extent ;  a  single  point  may  at  first  exhibit  the 
characteristic  appearance  of  a  chancroid,  and  the  remaining  portions  be 
only  gradually  involved. 

Period  of  Progress A  chancroid,  when  fully  formed,  is  usually  circular 

in  outline;  its  edges  are  abru})t  and  sliarply  cut ;  its  floor  is  uneven  and 
covered  with  a  grayish  secretion  ;  the  discharge  is  abundant  and  purulent ; 
its  base  presents  to  the  touch  the  normal  suppleness  of  the  underlying 
tissues ;  the  tendency  of  the  sore  is  to  extend  and  enlarge  its  area. 

Several  circumstances  may  render  the  outline  of  a  chancroid  other  than 
circular.  If  a  rent  or  abrasion  has  been  inoculated,  the  resulting  ulcer 
will  naturally  at  first  assume  a  corresponding  sliape.  If  two  or  more 
contiguous  ulcers  have  united,  the  outline  may  be  quite  irregular.  Certain 
situations  may  modify  the  form  of  tlie  chancroid ;  thus,  those  met  with  in 
tlie  furrow  at  the  base  of  the  glans  are  more  oval  than  circular,  probably 
owing  to  the  facility  with  Avhich  the  virus  flows  along  this  groove,  and 
macerates  and  inoculates  the  tissues  in  the  transverse  direction ;  for  a 
similar  reason,  chancroids  at  the  margin  of  the  anus  and  prepuce  tend  to 
follow  the  folds  of  tliese  orifices.  Moreover,  the  ulcer  would  appear  to 
extend  in  whatever  direction  the  tissues  are  most  lax  and  most  readily  per- 
meated by  the  virus;  thus,  if  a  chancroid  be  seated  in  part  upon  the  glrns 
and  in  part  upon  the  prepuce,  its  increase  is  the  more  rapid  upon  the  latter, 
and  its  outline  loses  the  circular  form. 

The  edges  of  a  chancroid  are  abrupt  and  sharply  cut  simply  because  the 
ulcer  penetrates  the  whole  thickness  of  the  skin  or  mucous  membrane. 
The  sore  is,  as  it  Avere,  punched  out  of  the  integumental  layer;  and  as  the 
ulceration  readily  encroaches  upon  the  lax  cellular  tissue  beneath,  the 
edges  are  often  undermined,  and  consequently  slightly  elevated  or  even 
everted ;  during  the  period  of  progress  they  are  also  somewhat  jagged,  as 
if  gnawed  by  the  erosion,  and  are  surrounded  by  an  areola  which  varies  in 
width  and  depth  of  color  according  to  the  degree  of  the  attendant  inflam- 
mation. 

The  floor  of  the  ulcer  is  uneven,  studded  with  minute  elevations,  "  worm- 
eaten,"  and  covered,  especially  at  the  centre,  with  a  pseudo-membranous 
secretion  of  a  grayish-yellow  color,  which  cannot  be  removed  without 
violence.  This  layer  is  made  up  of  the  disorganized  tissues.  Under  the 
microscope,  it  is  found  to  consist :  "1,  of  the  elastic  fibres  of  the  derma  ; 
2,  of  the  other  elements  of  the  integument  or  mucous  membrane,  more  or 


PERIOD    OF    PROGRESS — STATIONARY    PERIOD.  355 

less  changed,  and  reduced,  for  the  most  part,  to  an  amorphous  and  granu- 
lar mass;  3,  of  numerous  pus-globules."     (Cusco.) 

The  discharge  from  a  chancroid  is  somewhat  abundant,  and  decidedly 
purulent;  not  the  pure,  creamy  pus,  however,  which  we  see  in  the  acute 
stage  of  gonorrhoea,  and  from  which  it  may  be  readily  distinguished,  but 
thinner,  and  often  mixed  with  organic  detritus  or  streaked  with  blood. 
Mr.  Henry  Lee,  of  London,  regards  the  presence  of  pus-globules,  as  shown 
by  microscopical  examination,  in  the  secretion  of  a  venereal  ulcer  free 
from  irritation,  as  diagnostic  of  the  chancroid.  As  previously  stated,  the 
pus-globules  are  the  vehicle  of  the  chancroidal  poison,  and  the  secretion 
often  gives  rise  by  inoculation  to  successive  chancroids  in  the  neighborhood. 
The  condition  of  the  tissues  around  and  beneath  a  chancroid  is  one  of  the 
most  important  elements  of  diagnosis  between  it  and  a  true  chancre.  In 
the  former  the  parts  preserve  their  normal  softness  and  suppleness,  unless 
suVjjected  to  some  irritant,  or  attacked  by  simple  inflammation.  Inflam- 
matory engorgement,  however,  is  not  well  defined  like  the  specific  indura- 
tion of  the  initial  lesion  of  syphilis,  but  gradually  subsides  into  the  normal 
suppleness  of  the  neighboring  tissues  ;  it  is  also  less  firm,  and  of  a  more 
(loughy  feel,  and  disappears  shortly  after  the  cessation  of  the  inflammation 
which  occasioned  it.  The  application  of  any  astringent  lotion,  or  caustic, 
as  nitrate  of  silver,  potassa  fusa,  nitric  acid,  and  especially  corrosive  sub- 
limate or  chroraate  of  potash,  may  cause  hardness  which  so  closely 
resembles  s[)ecific  induration,  that  it  cannot  be  distinguished  from  it,  ex- 
cept by  its  shorter  duration  ;  and,  for  the  time  being,  the  diagnosis  must 
be  founded  upon  other  symptoms.  In  short,  as  regards  the  condition  of  its 
base,  the  chancroid  does  not  differ  from  any  simple  wound,  which,  when 
free  from  irritation,  is  soft  and  supple,  but  which  may  became  engorged 
from  any  of  the  ordinary  sources  of  inflammation.  The  fictitious  hardness 
which  sometimes  surrounds  a  chancroid  is  often  found  after,  the  applfcationi 
of  caustics  or  astringents  "to  mere  vegetations,  hei'petic  exulcerations,,  or 
other  solutions  of  continuity. 

The  pain  and  uneasiness  occasioned  by  a  chancroid  are  usually  only 
moderate,  tliougli  greater  than  tliose  attending  the  true  chancre.  They 
are  the  more  severe  the  more  rapidly  the  ulcer  extends,  and  are  heightened 
by  any  stretching  and  laceration  of  the  tissues,  or  by  the  application  of 
irritant  dressings  or  lotions.  They  diminish  and  disappear  as  the  repara- 
tive stage  sets  in. 

The  duration  of  the  progressive  stage  of  the  chancroid  is  very  variable, 
and  depends  very  much  upon  the  mode  of  treatment,  the  faithfulness  of 
the  patient  in  attending  to  the  sore,  and  also  upon  his  general  condition. 
It  is  rarely  less  than  four  or  five  weeks,  unless  cut  short  by  treatment, 
and  it  may  be  prolonged  for  montlis  or  years  by  the  causes  alluded  to,  or 
especially  by  tlie  supervention  of  [)hagedajna.  The  size  which  the  ulcer 
may  attain  is  subject  to  equal  variations,  and  dependent  upon  the  same 
causes ;  it  rarely  exceeds  that  of  a  twenty-five  cent  piece,  in  the  absence 
of  phagedaina  which  has  no  limit  to  its  action. 

Stationary  Period The   progress  of  a  chancroid  gradually  slackens 


356  CHANCROID. 

and  finally  becomes  imperceptible.  For  a  while  the  ulcei'  appears  to  be 
stationary.  It  makes  little  difference  whether  this  period  of  inactivity  is 
real,  or  whether  it  is  merely  apparent,  as  some  authors  would  have  us 
believe;  the  fact  remains  the  same,  that  the  progressive  force  of  the  virus 
seems  to  be  spent,  and  the  ulcer  remains  for  a  while  in  statu  quo^  prior  to 
any  signs  of  healing.  It  is  evident  that  this,  like  the  progressive  stage, 
must  be  variable  in  its  duration  in  different  cases,  and  subject  to  the  same 
influences. 

Reparative   Stage Tliis  stage  is  marked  by  several  changes  in  the 

appearance  of  the  ulcer.  The  inflammatory  areola,  if  such  has  existed, 
disappears,  and  the  neighboring  tissues  assume  a  healthy  aspect.  The 
floor  of  the  ulcer  also  "  clears  up  ;"  its  grayish  covering  becomes  thinner, 
and  is  soon  replaced  by  florid  granulations  which  spring  up  over  certain 
portions  of  the  sore,  generally  towards  the  circumference.  The  edges 
lose  their  reddish  color,  and  are  less  ])rominent;  they  can  no  longer  be 
everted,  but  become  adherent  to  the  sul)jacent  tissues;  and  their  margin, 
which  was  "sharply  cut,"  becomes  sloping.  No  decided  diminution  in 
the  area  of  the  ulceration  can  be  expected  until  the  loss  of  substance  is 
supplied  by  granulations.  The  patient  often  complains  that  his  sore  is  no 
smaller,  while  the  surgeon  can  see  that  its  floor  is  approaching  the  level 
of  the  surrounding  surface,  and  that  its  progress  is  all  that  could  have  been 
anticipated.  But  at  last,  a  fine  and  delicate  cicatricial  membrane,  which 
is  best  seen  with  a  magnifying  glass,  extends  from  the  margin  upon  the 
surface  of  the  ulcer.  Or,  in  exceptional  cases,  this  membrane  first  shows 
itself  at  some  point  within  the  circumference.  .  Macerated  by  the  discharge, 
it  has  a  whitish  look,  and  resembles  a  fragment  of  lint  which  has  not  been 
removed  at  the  last  dressing;  but  at  the  subsequent  visits  of  the  patient 
it  is  found  to  be  still  present,  gradually  increasing  in  size  until  it  becomes 
continuous  at  some  portion  of  its  periphery  with  the  margin  of  the  sore, 
and  it  thus  contributes  towards  the  final  closure  of  the  wound. 

It  was  at  one  time  supposed  that  a  chancroid  was  contagious  only  during 
its  progressive  and  stationary  periods,  and  that  its  virulence  ceased  either 
with,  or  soon  after  the  commencement  of  the  reparative  stage.  Fournier's 
experiments,  however,  have  shown  that  such  is  not  the  case,  and  that  even 
when  the  ulcer  is  already  far  advanced  towards  cicatrization,  the  tliin  and 
barely  purulent  secretion  from  its  surface  may  sometimes  be  inoculated 
with  success,  as  shown  by  the  following  table: — 

Fournier's  inoculations  during 
the  reparative  stage. 

1.  This  stage  fairly  established     . 

2.  This  stage  well  advanced 

3.  This  stage  nearly  completed 

It  is  thus  evident  that  it  is  never  safe  to  allow  patients  with  chancroids 
to  indulge  in  sexual  intercourse  until  the  ulcer  has  completely  closed. 

The  work  of  cicatrization  being  once  accomplished,  however,  the  chan- 
croid is  at  an  end  ;  without  a  fresh  contagion  there  can  be  no  subsequent 
relapse  or  .reopening  of  the  sore  with  its  former  virulence,  as  is  sometimes 


Result 

Re-ult 

positive. 

Degative. 

.     9 

3 

.     3 

0 

.     2 

5 

NUMBER    OF    CHANCROIDS.  357 

seen  with  the  true  chancre.  The  cicatrix  may  be  torn  or  abraded  at  will, 
only  a  simple  wound  can  be  reproduced,  and  not  a  virulent  ulcer,  and  this 
simply  for  the  reason  that  there  is  no  constitutional  infection  behind  the 
local  sore  to  regenerate  the  virus. 

The  scar  left  by  a  chancroid  varies  in  its  character  and  its  permanency 
according  to  the  extent  and  depth  of  the  ulceration,  and  also,  in  a  mea- 
sure, according  to  its  situation.  As  a  chancroid  is  usually  more  destruc- 
tive in  its  action  than  the  chancre,  so  the  former  is  much  more  likely  than 
the  latter  to  be  followed  by  a  cicatrix.  Upon  the  external  integument 
this  cicatrix  is  often  permanent ;  upon  a  moist  mucous  membrane  it  fre- 
quently fades  away  and  soon  becomes  effaced,  unless  the  ulceration  has 
produced  a  loss  of  substance  which  has  not  been  filled  up  during  the  re- 
parative stage. 

Number  of  Chancroids. — Patients  are  much  more  frequently  affected 
with  several  than  with  a  single  chancroid.  Thus,  in  327  cases,  observed 
chiefly  at  the  Hopital  du  Midi,  only  63  patients  had  a  single  ulcer,  or 
about  one  in  five.     Of  the  remaining  206,  there  were — 

Presenting  two           .........  50 

"           fi-om  three  to  six      .......  152 

"             "      six  to  ten         .......  45 

"              "      ten  to  fifteen 8 

"             "      fifteen  to  twenty      ......  5 

"             "      twenty  to  twenty-four     .....  6 

Total    .         .         .         .266 

Of  118  men  who  were  admitted  at  the  Antiquaille  Hospital,  Lyons,  M. 
Debauge  found — 

Presenting  a  single  ulcer  ........  50 

"           two 22 

"           four n 

"           five 11 

"  from  six  to  ten          .          .         .         .         .         .         .17 

"  "       eleven  to  fifteen        ......  6 

"  twenty     .........  1 

Total         .         .         .         .118 

Sometimes  the  chancroid  is  multiple  from  the  first ;  more  frequently  it 
becomes  so  by  successive  inoculation  of  points  in  the  neighborhood  of  its 
original  site.  The  first  ulcer  pours  out  an  abundant  secretion,  and  its  pre- 
sence confers  no  immunity  against  others.  We  shall  see  hereafter  how 
0|)posite  is  the  case  witii  the  true  chancre,  the  initial  lesion  of  syphilis. 

The  ciiancroid  is  multiple  from  the  outset  only  when  several  points 
have  been  inoculated  at  the  time  of  contagion.  It  is  evident  that  certain 
regions  will  militate  either  for  or  against  successive  inoculation.  Thus,  if 
the  sore  ha  situated  upon  the  external  integument,  as  tlie  sheath  of  the 
penis,  the  virus  is  not  likely  to  find  a  door  of  entrance  within  the  hardened 
epidermis  of  the  surrounding  suHace.  On  the  other  hand,  if  it  be  seated 
at  the  base  of  the  glans,  its  secretion  will  extend  along  tlie  furrow,  mace- 


358  CHANCROID. 

rate  the  thin  epithelium,  and  will  generally  occasion  successive  inocula- 
tions, especially  in  cases  complicated  with  phimosis. 

M.  Clerc^  states  that  successive  chancroids  are  generally  mild  in  their 
character  compared  with  the  original  sore  ;  that  they  usually  occupy  a 
less  extent  of  surfixce,  and  that  they  tend  to  heal  more  speedily  ;  and  I 
think,  judging  from  my  own  observation,  that  this  rule  will  be  found  to 
be  true  generally,  although  not  invariably. 

Condition  of  the  neighhoring  Ganglia In    the  majority  of  cases  of 

chancroid,  or,  as  nearly  as  we  can  determine  by  statistics,  in  about  two 
cases  out  of  three,  the  neighboring  lymphatic  ganglia  remain  intact  through- 
out the  whole  course  of  the  disease.  In  the  remaining  minority,  these 
bodies  take  on  inflammatory  action,  either^/'s^,  as  the  result  of  the  exten- 
sion of  simple  inflammation  from  the  local  ulcer  along  the  course  of  the 
lymphatics,  or  secondly,  in  consequence  of  the  absorption  and  conveyance 
to  the  ganglion  of  the  chancroidal  virus.  In  the  former  case  (inflamma- 
tory or  simple  bubo),  resolution  is  possible  without  suppuration  ;  in  the 
latter  (virulent  bubo),  supi)uration  is  inevitable.  Of  207  cases  of  chan- 
croid observed  at  the  Hopital  du  Midi  in  one  year,  05  were  attended  with 
bubo,  and  142  were  not.^  Of  140  patients  in  the  service  of  M.  Rollet,  at 
Lyons,  57  were  free  from  inguinal  reaction,  while  83  had  buboes,  of  which 
60  were  virulent.^  We  shall  see  hereafter  that  the  initial  lesion  of  syphilis 
is  always  attended  with  induration  of  the  nearest  lym[)hatic  ganglia,  which 
rarely  become  inflamed  and  suppurate,  and  it  cannot  be  too  often  im- 
pressed upon  the  mind  of  the  student  that  an  examination  of  the  ganglia 
in  the  neighborhood  of  a  venereal  ulcer  affords  assistance  of  the  highest 
value  in  distinguishing  a  chancroid  from  primary  syphilis. 

Varieties  of  the   Chancroid There  is  a  form  of  the  chancroid 

called  by  M.  Clerc  the  exidcerons.  In  this  variety,  the  sore  is  little,  Jf 
at  all,  depressed  below  the  level  of  the  surrounding  surface,  and  conse- 
quently its  edges  are  not  perpendicular  and  sharply  cut.  Otherwise  its 
appearance  is  the  same  as  already  described  ;  its  floor  is  irregular,  and 
covered  with  a  grayish  secretion ;  its  discharge  abundant  and  purulent, 
and  its  base  soft.  This  variety  is  sometimes  observed  on  the  margin  of 
the  prepuce,  in  cases  of  phimosis  with  concealed  chancroids  at  the  base  of 
the  glans. 

Again,  the  chancroids  may  vegetate  above  the  surface,  and  constitute 
one  form  of  what  has  been  described  as  the  ulcus  devatum. 

When  the  virus  has  gained  entrance  within  a  follicle,  and  inoculated 
its  internal  surface,  the  chancroid  may  at  first  appear  like  a  pustule  of  acne 
indurata.  Ulceration  soon  commenoes  at  a  minute  point  upon  the  surface, 
and  gradually  extends  until  it  lays  open  a  sore  presenting  the  usual  char- 
acteristics of  a  chancroid.  This  variety  is  knovvn  as  the  follicular  form. 
Cullerier  depicts  a  number  of  such  sores  upon  the  external  surface  of  the 

'  Traite  jn-atique,  p.  182.  2  Foukniek,  op.  cit.  p.  34. 

3  Debauge,  oj).  cit.  p.  72. 


DIAGNOSIS    OF    THE    CHANCROID.  359 

labia  niajora  and  inner  surface  of  the  thighs.^  This  is  an  important  variety 
of  the  chancroid,  liable  to  be  overlooked,  and  should  be  borne  in  mind  hj 
the  student. 

The  ecthymatoas  form  is  nothing  more  than  a  chancroid  which,  from 
exposure  to  the  air,  has  become  covered  with  a  scab,  composed  of  its 
dried  secretion.  It  is  evident  that  this  form  is  not  likely  to  be  met  with 
except  upon  the  external  integument. 

The  form  of  the  chancroid  may  be  modified  by  its  seat,  as  will  be  de- 
scribed in  tlie  next  chapter. 

Diagnosis  of  the  Chancroid — In  the  great  majority  of  cases,  a 
chancroid  is  readily  recognized  by  a  practised  eye,  from  its  various  symp- 
toms already  described ;  yet  there  is  not  a  single  one  of  these  symptoms 
which  may  not  be  found  in  lesions  of  an  entirely  diflerent  nature. 

It  was  formerly  supposed  that  an  unfailing  and  absolute  test  of  a  chan- 
croid was  to  be  found  in  its  experimental  inoculation  upon  the  person 
bearing  it ;  if  auto-inoculation  pi'operly  performed  was  successful,  it  was 
inferred  that  the  sore  must  be  a  chancroid  ;  if  unsuccessful,  it  could  not  be. 
We  cannot  now  rely  upon  this  test  so  implicitly,  tor  reasons  that  will  be 
obvious  to  the  reader  of  the  preceding  pages ;  at  the  same  time,  the  ready 
auto-inoculation  of  any  sore  affords  a  sti'ong  ground  of  probability  that  it 
is  of  this  nature. 

The  method  of  performing  artificial  inoculation  has  already  been  given, 
and  I  have  only  to  add  a  few  precautions  concerning  it.  In  the  first  place, 
while  this  experiment  is  of  great  practical  value,  and,  if  properly  per- 
formed, Usually  devoid  of  danger,  yet  it  should  not  be  rashly  resorted  to, 
and  should  only  be  employed  either  for  the  benefit  of  the  ])atient  or  the 
interests  of  science.  In  careless  hands,  very  troublesome  and  even  serious 
results  have  been  known  to  follow.  I  have  myself  seen  two  such  cases  ; 
one  in  the  New  York  Hospital,  in  which  artificial  inoculation,  performed 
before  the  patient's  entrance,  had  given  rise  to  an  extensive  ulcer  upon 
the  thigh  of  several  years'  duration  ;  and  another  similar  case  in  the 
Pennsylvania  Hospital,  Philadelphia.  Other  cases  are  reported  in  works 
on  venereal.  Such  evil  results  may,  I  believe,  be  avoided  l)y  observing 
the  following  simple  rules  : — 

1.  Avoid  artificial  inoculation  in  all  cases  of  phagedenic  ulcers,  and  in 
all  persons  of  a  broken-down  constitution,  for  fear  that  the  inoculated 
point  may  lake  on  ulcerative  action  whicii  will  be  beyond  the  control  of 
caustics. 

2.  Avoid  artificial  inoculation,  unless  you  are  reasonably  certain  of 
having  the  patient  under  your  continued  observation.  Hence  this  method 
of  diagnosis  may  be  used  much  more  freely  in  hospitals  than  in  [)rivate 
jtractice. 

3.  SoJect  as  a  site  for  the  inoculation  some  portion  of  the  integument, 
as  the  chest,  Avhere  experience  proves  the  occurrence  of  phagedaena  to  be 
rare. 

'  Cl'Llekieu  and  Bumstead's  Atlas,  1*1.  ix,  fig.  1. 


360  CHANCROID. 

4.  INIake  your  incision  no  deeper  tlian  the  surface  of  the  vascular  hxyer 
of  the  skin,  for  a  reason  previously  given. 

5.  Thoroughly  cauterize  the  inoculated  point  with  a  strong  caustic,  as 
nitric  acid  or  tlie  carbo-sulphuric  paste,  as  soon  as  the  diagnosis  of  a  re- 
sulting chancroid  can  be  made. 

The  value  of  this  test  depends,  of  course,  upon  the  thoroughness  of  its 
application.  Unless  the  matter  be  implanted  under  the  requisite  condi- 
tions, it  cannot  take  effect. 

Other  points  of  distinction  between  the  chancroid  and  those  lesions  most 
apt  to  be  mistaken  for  it  now  claim  our  attention. 

An  abrasion  due  to  violence  during  coitus  will  be  recognized  by  the 
patient  himself — unless  intoxicated — either  at  the  time  of  its  occurrence, 
or  during  those  reflective  moments  which  follow  the  exposure.^  Independ- 
ently of  its  history,  an  abrasion  may  often  be  recognized  by  the  jagged 
outline  of  its  edges  and  by  the  appearance  of  its  surface  and  its  secretion, 
differing  as  they  do,  from  those  of  a  chancroid  already  described.  Sub- 
sequent neglect,  a  low  condition  of  the  general  system,  the  accumulation 
of  filth  or  even  of  the  natural  secretion  of  the  part,  may  perpetuate  the 
solution  of  continuity  thus  made,  and  transtbrm  it  into  an  ulcer  which  can 
with  difficulty  be  distinguished  from  a  chancroid  ;  and  the  diagnosis  can 
only  be  made  either  by  artificial  inoculation  or  by  waiting  for  farther  de- 
velopments, at  the  same  time  paying  attention  to  cleanliness  and  to  general 
hygiene.  "  But,"  it  may  be  said,  "an  abrasion  occurring  at  the  time  of 
coitus  may  have  served  as  the  door  of  entrance  either  to  the  chancroidal 
or  syphilitic  poison."  Very  true;  and  consequently  wlien  a  patient  seeks 
advice,  a  few  days  after  coitus,  with  a  solution  of  continuity  evidently  due 
to  violence,  the  surgeon  can  only  estimate  its  present  but  not  its  future  char- 
acter. Under  such  circumstances,  a  guarded  opinion  only  should  be  given, 
as  for  instance,  "  You  have  torn  yourself  in  the  sexual  act;  but  whethej' 
you  have  been  inoculated  or  not  through  the  rent,  1  cannot  say  ;  time  will 
determine."  A  mere  abrasion  or  tear,  in  a  healthy  constitution,  and  under 
conditions  of  cleanliness,  will  heal  in  the  course  of  a  few  days;  while  an 
abrasion  inoculated  with  the  chancroidal  virus  will  extend  and  assume  the 
character  of  a  chancroid. 

An  eruption  of  herpes  usually  appears  on  the  first  or  second  day  after 
exposure,  is  attended  with  itching,  and  consists  of  a  number  of  small  vesi- 
cles which  are  arranged  in  one  or  more  grou])S  affecting  the  form  of  a 
circle.  The  contained  fluid  soon  becomes  turbid,  and  if  the  epidermis  be 
ruptured  or  removed,  a  superficial  ulceration  is  found  beneath.  With 
attention  to  cleanliness  and  the  interposition  of  a  piece  of  dry  lint  between 
the  glans  and  prepuce,  the  vesicles  or  erosions  will  usually  heal  in  the  course 

'  There  is  an  old  adage  bearing  on  this  point  commencing  "  Omnennimnl  poM  coitum 
trlste  est,^'  etc.,  wliicli  the  able  reviewer  of  the  last  edition  of  this  book  in  the  Am. 
.lour.  Med.  Sci.  corrects  me  in  having  attributed  to  Aristotle,  of  whom,  however,  it 
would  have  been  worthy.  The  reviewer  is  shocked  at  the  allusion  to  tliis  adage 
in  a  scientific  book,  and  I  will  therefore  refer  to  his  own  article  in  the  Am.  Jour. 
Med.  Sci.,  .Jan.  1S71,  where  he  gives  the  text  in  full. 


DIAGNOSIS    OF    THE    CHANCROID  361 

of  a  few  days.  Their  circular  arrangement,  small  size,  watery  contents, 
superficial  character,  the  pruritus  which  they  occasion,  and  their  speedy  cica- 
trization, present  n  marked  contrast  to  the  symptoms  of  the  chancroid. 
Again,  in  many  cases,  we  find  on  inquiry  that  the  patient  has  been  subject  to 
herpes,  which  recurs  upon  the  slightest  provocation,  as  after  coitus  with  any 
woman  however  pure,  or  after  dining  out  or  indulgence  in  wine,  and  in  some 
instances  without  apparent  cause. ^  The  discovery  of  this  fact  should  put  us 
upon  our  guard,  and  lead  us  to  resort  toother  means  of  diagnosis  in  doubt- 
ful cases.  The  diagnosis  between  herpes  and  the  chancroid  may,  therefore, 
be  said  in  general  to  be  easy ;  but,  as  noticed  by  Fournier,  there  is  a  rare 
form  of  herpes  consisting  of  a  single  and  somewhat  excavated  ulceration, 
which  very  closely  resembles  a  chancroid,  and  which  in  some  instances 
cannot  be  distinguished  from  it  except  by  inoculation. 

I  shall  defer  the  consideration  of  tlie  diagnostic  signs  of  the  chancroid 
and  cliancre  until  I  come  to  speak  of  syphilis. 

Witii  regard  to  mucous  patches,  which  are  so  often  seated  U]jon  the 
genital  organs,  their  superficial  character,  the  history  of  the  case,  and  the 
coexistence  of  other  secondary  symptoms  ai*e  commonly  sufficient  to  enable 
us  to  distinguish  them. 

There  is  another  class  of  cases,  fortunately  uncommon,  in  which  the 
diagnosis  is  less  easy,  and  which  sometimes  occasion  much  annoyance. 
I  refer  to  old  syphilitic  patients,  who  have  probably  advanced  to  the 
tertiary  stage  of  the  disease.  These  men  occasionally  make  their  ap- 
pearance with  an  ulceration  closely  resembling  a  chancroid,  with  sharply- 
cut  edges,  a  grayish  excavated  floor,  an  abundant  purulent  secretion,  and 
a  soft  base,  which  I  have  seen  most  frequently  in  the  furrow  at  the  base  of 
the  glaris  where  it  tends  to  undermine  the  integument  of  the  penis.  It 
also  occurs  on  the  surface  of  the  glans  and  at  the  meatus.  The  glands  of 
the  groin  are  not  affected.  On  inquiry  you  find  that  the  patient  has  not 
presented  any  sypliilitic  symptoms  for  months  or  even  years,  and  exami- 
nation of  other  parts  of  tlie  body  may  fail  to  show  any  evidence  whatever 
that  the  poison  is  still  active.  Very  likely,  also,  the  man  is  of  dissipated 
habits  and  has  frecpiently  been  exj)Osed  of  late  in  promiscuous  intercourse, 
so  that  chancroidal  contagion  is  highly  probable.  All  the  circumstances, 
therefore,  except,  perha{)S,  the  fact  that  the  sore  is  solitary  in  a  region 
where  the  chancroid  is  almost  always  multii»le,  point  to  the  simple  chancre  ; 
and  yet  if  you  treat  it  as  such  with  caustics,  cleanliness,  astringent  lotions, 
etc.,  you  fail  utterly,  but  it  heals  under  the  mixed  constitutional  treatment 
of  iodide}  of  potassium  and  mercury.  ^ 

I  have  one  patient  in  mind,  in  whom  these  symptoms  occurred  some  four 
to  six  times  during  a  period  of  several  years,  the  last  time  six  months  after 
his  marriage,  during  which  I  have  reason  to  believe  that  he  had  not  been 
exposed  to  contagion.  Another  instance  is  that  of  a  medical  man,  who 
has  had  tfiree  attacks  of  the  kind.     AVlien  I   first   met  with  these  cases,  I 

'  Dr.  A.  DoYON  lias  written  an  interesting  monograph  on  this  form  of  lierpes, 
entitled  De  I'herpes  recidivant  des  parties  genitales,  Paris,  1868. 


362  CHANCROID. 

was  quite  at  a  loss  regarding  them,  but  further  study  of  numerous  cases  has 
shown  them  to  be  ulcerated  gummata  of  the  glans. 

In  arriviijg  at  a  diagnosis  of  the  chancroid,  as  well  as  of  other  venereal 
diseases,  especially  in  their  early  stages,  the  value  of  the  confrontation  of 
patients  should  not  be  forgotten.  Tlie  recipient  can  have  no  other  disease 
than  that  possessed  by  the  giver,  in  whom  the  symptoms  are  probably  more 
marked,  because  they  have  had  a  longer  time  for  development. 

I  would  also  call  the  reader's  attention  to  the  possibility  of  the  double 
inoculation  of  the  chancroidal  and  syphilitic  poisons,  or  to  what  has  been 
improperly  called  the  "  mixed  chancre,"  which  we  shall  consider  here- 
after ;  and  again  to  the  occasional  develo])ment  of  a  chancroid  upon  the 
old  induration  of  a  chancre,  which  is  very  apt  to  lead  to  error  in  the  diag- 
nosis, on  account  of  the  hardness  of  the  base  of  the  sore. 

After  all,  cases  do  occur,  in  which  auto-inoculation  is  impracticable,  and 
in  which  the  diagnosis  is  for  a  time  impossible.  A  degree  of  rapidity  and 
facility  in  diagnosis  with  regard  to  venereal  diseases,  is  often  demanded  by 
patients  and  even  by  physicians,  which  it  is  simply  unreasonable  to  expect. 
The  specialist  is  expected  to  be  able  to  decide  at  once  in  all  cases,  from  a 
single  examination,  and  often  with  a  very  imperfect  knowledge  of  the  his- 
tory, whether  a  given  sore  is  a  chancroid,  a  chancre,  an  herpetic  ulceration, 
etc.  Now,  the  same  latitude  should  be  allowed  here  as  obtains  in  other 
diseases.  Doubtful  cases  will  occur,  with  regard  to  which  the  most  ex- 
perienced specialist  must  for  a  time  be  undecided,  and  he  will,  if  an  honest 
man,  confess  his  ignorance  rather  than  assume  knowledge  which  he  does 
not  possess. 

It  is  important  to  distinguish  between  the  chancroid  and  epithelioma  or 
cancer  of  the  penis.  I  was  called  in  consultation  by  a  country  physician, 
to  see  a  case  of  supposed  venereal  ulcer  of  the  glans  penis.  The  patient 
was  a  married  man,  and,  the  diagnosis  of  his  doctor  having  become  known, 
his  reputation  was  ruined.  I  found  it  to  be  a  case  of  epithelioma,  and  am- 
putated the  organ. 

E[)ithelioma  is  more  frequent  than  true  cancer,  in  the  proportion  of  five 
to  one  (Demarquay).  In  the  majority  of  cases,  it  commences  in  the  glans 
or  prepuce,  and  may  extend  to  the  corpora  cavernosa  or  involve  the  whole 
penis.  The  glands  in  the  groin  are  subsequently  engorged,  and  become 
deeply  and  extensively  idcerated. 

Epithelioma  usually  commences  as  an  irregular  warty  excrescence,  which 
soon  ulcerates,  and  presents,  at  first,  superficial  erosions  covered  with  sa- 
nious  mister.  There  follow  deep  and  irregular  excavations  and  cauliflower 
excrescences.  The  surrounding  skin  is  tumefied  and  scattered  over  with 
tubercles,  w'hich  in  their  turn  become  degenerated  and  add  to  the  extent 
of  the  disease.  "  By  pressure  upon  these  papillary  tumors,  plugs  of  flat- 
tened or  cylindrical  epithelial  cells,  resembling  the  sebaceous  matter  of 
comedones,  can  be  squeezed  out."     (Klebs.) 

True  cancer  may  be  either  of  the  scirrhous  or  encephaloid  form,  but 
more  frequently  the  latter.  Lebert  says  that  in  most  cases  the  form  is 
intermediate  between  the  two.     True  cancer  may  at  the  same  time  affect 


PROGNOSIS  —  PATHOLOGICAL    ANATOMY.  363 

distant  organs,  while  the  influence  of  epithelioma  is  never  seen  beyond  the 
inguinal  glands.  In  a  large  majority  of  cases,  these  affections  occur  in 
persons  who  have  permanent  phimosis,  either  congenital  or  accidental. 

The  distinction  between  epithelioma  and  true  cancer  on  the  one  hand 
and  the  chancroid  and  truly  syphilitic  lesions  on  the  other,  is  not  always 
easy.  The  amount  of  pain  is  7iot  always  a  reliable  sign,  for  this  may  be 
absent  for  some  time  even  in  true  cancer.  The  diagiiosis,  however,  may 
usually  be  made  out  from  the  history  of  the  case,  from  the  appearance  of 
the  surface,  base,  and  edges  of  the  ulcer,  and  from  its  progress.  In  doubt- 
ful cases,  the  patient  should  have  the  benefit  of  a  trial  of  treatment  adapted 
to  venereal  ulcerations  (whether  chancroidal  or  sy^jhilitic)  before  amputa- 
tion is  resorted  to. 

Pkognosis  OF  THE  Chanoroid The  chancroid,  aside  from  its  com- 
plications, is  of  less  serious  import  than  either  the  chancre  or  gonorrhu?a; 
less  so  than  the  chancre,  because  it  does  not  depend  upon  and  is  never 
followed  by  constitutional  infection,  and  less  so  than  gonorrhoea,  because 
it  does  not  result  in  deep-seated  urethral  contractions.  A  chancroid  at 
the  meatus  will  indeed  probably  produce  a  stricture  at  this  point,  but  one 
which  is  amenable  to  treatment  and  unattended  with  danger. 

The  presence  of  complications  may  add  seriously  to  the  gravity  of  the 
disease.  Phimosis  may  result  in  gangrene  and  loss  of  the  prepuce. 
Lymphitis  or  adenitis  may  confine  the  patient  to  his  bed  for  months ;  and, 
above  all,  the  occurrence  of  phagedaina  may  involve  the  destruction  of 
important  tissues  or  organs,  or  be  the  source  of  misery  and  suffering  for 
many  years.     Tliese  complications  will  be  described  in  another  chapter. 

The  chief  point,  however,  Avhich  commonly  excites  the  anxiety  of  the 
patient  is  with  regard  to  constitutional  infection,  and  of  this  the  surgeon 
may  assui'c  him  there  is  no  danger. 

Pathological  Anatosiy Kaposi^  gives  the  following  description  of 

the  microscopical  appearances  of  the  "soft  chancre"  (chancroid)  : — 

"Microscopical  examination  of  a  perpendicular  section,  including  the 
margin,  the  inflamed  parts  in  the  neighborhood,  together  with  a  portion 
of  the  floor  and  the  inflamed  base  of  the  ulcer,  shows  that  the  portion  of 
the  skin  occupied  by  the  chancroid,  consists  of  two  parts,  which  have 
evidently  undergone  different  anatomical  changes. 

"  From  the  floor  of  the  ulcer  (Fig.  112,  cd)  to  a  considerable  depth  in 
the  corium  is  a  uniform  and  uncommonly  thick  cell-inflltration,  which 
terminates  sharply  at  the  line  fg.  This  infiltration  is  continued  beneath 
the  intact  papilla?  of  the  margin  of  the  ulcer  {el),  and  laterally  far  beyond 
the  limits  of  its  floor  [k).  The  tissue  bordering  on  the  infiltrated  mass 
(/(/,  hi)  is  composed  of  loose  meshes,  and  exhibits  scattered  cells  with  a 
large  nucleus,  that  is  well  brought  out  by  carmine. 

'  Syphilis  der  Haat  und  der  angroiizondon  Schleimhiivite,  1  Liefcruiig,  s.  42, 
Wien,  1873. 


364 


CHANCROID. 


"  In  the  swollen  margin  (ftb)  a  number  of  the  papilla?  (e)  lying  nearest 
to  the  floor  of  the  ulcer  are  thickened  and  closely  infiltrated  with  cells. 
The  layer  of  Malpigliian  cells  between  these  papilli\3  is  thickened. 

"  The  floor  of  the  ulcer  [cd)  is  formed  by  the  exposed,  cell-infiltrated 
corium,  and  is  destitute  of  papilla;.  Both  the  corium  and  papilke,  wherever 
infiltrated  with  cells,  exhibit  numerous  enlarged  vessels,  the  most  of  which 
are  bloodvessels,  but  a  few  are  lymphatics. 


Fig.  112. 


Section  of  a  chancroid.  Hai-tnack,  oc.  3,  obj.  4.  (After  Kaposi.)  ab,  swollen  niaririn  of  the 
chancroid,  cd,  floor  of  same,  be,  e|iiderinis.  e,  undermined  border,  cd,  fij,  tissue  infiltrated 
with  small  cells  and  traversed  by  several  dilated  vessels,  fg,  hi,  tissue  subjacent  to  the  ba.se 
of  the  chancroid,  composed  of  larf,'e  (edematous  meshes  free  from  cellular  infiUration.  «,  enlarged 
papillaj  infiltrated  with  cells,  k,  continuation  of  the  tissue  iiifiltJated  with  cells  beneath  the 
papillae  at  the  margin  of  the  ulcer,  which  still  remain  intact. 

"  Under  a  high  jiower,  tlie  cell-infiltrated  portion  consists  of  a  close 
network  of  partly  narrow,  partly  broad,  bundles  of  fibi-es  with  faint  con- 
tours, in  which  is  deposited  a  great  number  of  nucleated  and  evenly  dis- 
tributed cells,  some  of  them  very  large  and  resembling  lymph-corpuscles, 
and  others  smaller.  The  cells  lying  near  the  floor  of  the  ulcer  and  the 
neighboring  parts  are  mostly  small  and  irregular  in  outline,  with  scattered 
nuclei.     Free  nuclei  and  nucleoli  are  also  found  in  large  numbers. 

"  In  the  deeper  tissues  the  cells  have  generally  the  appearance  of  in- 
flammatory-cells, but  there  are  also  many  smaller  ones. 


TREATMENT    OF    THE    CHANCROID.  365 

"  Of  great  interest  is  the  remarkable  thickening  of  the  walls  of  the 
vessels,  the  cavities  of  which  appear  to  be  enlarged  both  in  the  infiltrated 
and  the  neighboring  oederaatous  portions. 

"  The  degeneration  of  the  tissue  and  of  the  infiltrated  cells  takes  place 
only  in  the  upper  portion,  and  to  an  extent  which  is  but  limited  in  pro- 
portion to  the  extent  and  depth  of  the  infiltration.  Interstitial  abscesses 
do  not  exist.  We  have  not  found  any  characteristics  which  would  enable 
us  to  distinguish  the  cell-infiltration  of  the  corium  and  ])apillre  or  the  sub- 
sequent degeneration  of  the  same  from  similar  processes  of  simple  origin." 

Treatment  of  the  Chancroid.  Prophylaxis The  use  of  a  con- 
dom will  protect  those  parts  which  it  covers  from  contagion,  but  the 
neighborliood  of  the  root  of  the  penis,  as  the  scrotum  and  pubes,  will  still 
be  exposed.  As  Kicord  was  wont  to  express  it  in  his  lectures,  "  carrying 
an  umbrella  over  the  head  in  a  rainstorm  will  not  prevent  the  feet  from 
getting  wet."  Whether  any  such  protective  covering  has  been  used  or 
not,  the  genital  organs  should  be  assiduously  cleansed  after  any  suspicious 
connection,  especially  in  those  folds,  as  in  the  furrow  at  the  base  of  the 
glans,  where  contagious  matter  is  most  likely  to  be  deposited. 

General  Treatment — The  internal  use  of  mercury  has  no  beneficial 
influence  whatever  upon  the  chancroid,  which  continues  in  a  state  of 
stubborn  persistency,  or  even  progresses,  after  the  system  is  fully  under 
the  influence  of  this  mineral.  This  statement  is  not  a  mere  inference 
from  the  distinct  nature  of  the  chancroid  and  syphilis,  but  is  founded  upon 
experience.  I  was  fully  convinced  of  the  fact  by  personal  observation, 
and  ceased  to  employ  mercury  for  "  soft  chancres,"  several  years  before 
the  distinction  between  the  two  species  was  recognized.  Since  abandon- 
ing it  in  my  own  practice,  I  have  had  numerous  opportunities  of  observin"' 
other  surgeons  administer  mercurials  for  the  chancroid,  and  my  former 
opinion  has  only  been  confirmed. 

In  most  instances  no  general  treatment  is  required,  except'tliat  which 
common  sense  would  dictate,  and  which  has  for  its  object  to  place  the 
patient  in  a  healthy  condition  and  thereby  enable  nature  untrammelled  to 
accomplish  the  work  of  cure.  For  this  purpose,  the  secretions  should  be 
attended  to;  a  plain  but  nourishing  diet  administered;  and  congestion  and 
inflammation  avoided  by  maintaining  a  comparative  state  of  (piietude. 
Nocturnal  erections  are  not  only  painful  but  interfere  with  cicatrization, 
and  should  be  controlled  by  the  means  mentioned  when  speaking  of 
cliordee. 

Abortive  Treatment — This  treatment  has  for  its  object  the  removal  or 
destructi(»n  of  the  virulent  ulcer,  and  the  substitution  for  it  of  a  simple 
wound,  the  tendency  of  which  shall  be  to  heal.  The  removal  of  the  ulcer 
is  accomplished  by  cutting  instruments  ;  its  destruction  by  the  more  power- 
ful caustics. 

Practically,  we  find  that  the  excision  of  a  chancroid  is  rarely  successful. 
However  carefully  tlie  sore  and  the  surrounding  surface  may  have  been 
cleansed  of  its  secretion  before  the  operation,  the  fresh  wound   usually  be- 


366  CHANCROID. 

comes  inoculated  ;  either  the  incision  lias  not  been  carried  wide  enough 
from  the  "sphere  of  specific  action,"  or  in  spite  of  our  precautions,  some 
of  the  virus  has  remained  upon  the  surface ;  and  we  now  are  worse  off 
than  before,  because  we  have  a  large  virulent  ulcer  instead  of  a  small  one. 
For  this  reason,  excision  should  be  employed  only  in  certain  situations,  as 
in  cases  of  chancroids  upon  the  margin  of  the  prepuce  or  the  free  border 
of  the  labia  minora,  where  the  knife  or  scissors  can  be  carried  wide  of  the 
ulcer,  and  the  bleeding  surface  should  be  fi-eely  cauterized,  so  that  it  may 
for  a  time  be  protected  by  an  eschar. 

Destructive  cauterization  is  much  more  frequently  employed  than  ex- 
cision ;  hut  is  only  adapted  to  the  curly  staye  of  the  chancroid — say  within 
the  first  five  or  ten  days  of  its  existence — when  it  may  act  as  a  true 
"  abortive"  method,  cutting  short  the  duration  of  the  ulcer,  preventing 
inoculation  of  parts  in  the  neighborhood,  and  averting  all  danger  of  gan- 
glionary  reaction.  A  few  years  ago  it  was  much  more  frequently  resorted 
to  than  at  the  present  time,  and  patients  were  subjected  to  much  sutl'ering 
from  which  they  might  have  been  spared.  The  chancroid  under  proper 
attention  to  cleanliness  and  mild  local  apj)lications,  will  in  the  great 
majority  of  cases  soon  take  on  reparative  action,  and  with  the  discovery 
of  the  healing  power  of  iodoform,  we  are  now  able  to  obtain  even  better 
results  than  formerly,  when  cauterization  was  the  rule  and  not  the  excep- 
tion in  treatment.  In  private  practice,  I  do  not  recollect  having  applied 
a  strong  caustic  to  a  chancroid  five  times  within  a  year.  Let  it  he  under- 
stood then,  that  destructive  cauterization  as  an  a,hortiiie  metliod  is  recom- 
mended solely  in  the  earliest  stage  of  the  chancroid. 

If  applied  sufficiently  early,  it  prevents  the  occurrence  of  virulent 
buboes  by  removing  the  source  from  which  the  poison  enters  the  lym- 
phatics ;  but  if  deferred  until  a  bubo  has  commenced,  the  latter  goes  on  to 
sui)puration  unchecked,  and  may  furnish  inoculable  pus  in  the  same 
manner  as  if  the  chancroid  had  been  allowed  to  remain.  Even  the  simple 
bubo  is  often  benefited  by  destruction  of  the  ulcer  and  undergoes  resolu- 
tion.^ 

Destructive  cauterization  is  impracticable  Avhen  the  chancroid  cannot 
be  fully  exposed,  as  in  consequence  of  phimosis,  concealment  within  the 
urethra,  os  uteri,  etc.  It  is  inadmissible  in  ulcers  situated  directly  over 
the  urethra  either  in  the  male  or  female  on  account  of  the  danger  of  open- 
ing this  passage;  for  a  similar  reason,  in  chancroids  of  the  deeper  portions 
of  the  vagina,  the  walls  of  which  are  in  contact  with  the  bladder,  rectum, 
or  peritonteum ;  in  those  upon  the  margin  of  the  meatus,  from  the  fear  of 
the  cicatrix  occasioning  stricture ;  and,  finally,  in  all  cases  in  which  the 
presence  of  other  ulcers  in  the  neighboi'hood,  which  cannot  be  subjected 
to  the  same  treatment,  would  expose  the  wound  after  the  fall  of  the  eschar 
to  a  second  inoculation.^  Thus  it  would  be  useless  to  attempt  the  destruc- 
tion of  a  chancroid  upon  the  margin  of  the  prepuce  in  a  case  of  phimosis 

•  RoLLET,  Gaz.  mdd.  de  Lyon,  March  1,  1858. 

*  De  la  methode  destructive  des  chancres,  par  M.  Dion  ;  Annualre  de  la  sypli. 
et  d.  mal.  de  la  peau,  Paris.     Ann^e  1858,  p.  202. 


CHOICE    OF    A    CAUSTIC.  367 

with  concealed  chancroids  within,  since  the  secretion  from  the  latter  would 
be  sure  to  inoculate  the  wound  after  the  slough  comes  away. 

If  the  application  of  the  caustic  has  been  successful,  a  healthy  granu- 
lating wound  will  be  left  on  the  fall  of  the  eschar.  If  the  sore  still  present 
the  appearance  of  a  virulent  ulcer,  even  only  over  a  portion  of  its  surface, 
the  caustic  should  be  reapplied. 

Choice  of  a  Caustic. — Works  upon  materia  medica  inform  us  that  the 
nitrate  of  silver  is  superficial  in  its  action,  and  incapable  of  affecting  the 
tissues  beyond  the  surface  to  which  it  is  applied,  yet  this  is  the  caustic 
selected  by  the  great  majority  of  the  profession  for  the  purpose  of  destroy- 
ing a  chancroid!  Let  a  patient  with  a  rent,  abrasion,  or  ulceration 
following  suspicious  intercourse,  apply  to  any  one  of  four  doctors  out  of 
five,  "as  doctors  run,"  and  his  sore  will  be  daubed  with  a  stick  of  lapis 
infernalis.  With  what  result?  The  part  is  irritated  and  the  patient's 
suffering  increased ;  the  symptoms  are  obscured  and  an  accurate  diagnosis 
rendered  for  a  time  difficult  or  impossible;  if  the  sore  heals,  the  nitrate 
has  the  credit  of  destroying  a  chancroid,  or,  perhaps,  of  "  preventing  con- 
stitutional infection;"  at  any  rate  the  patient's  mind  is  relieved  by  the 
idea  that  "something  has  been  done,"  and  the  surgeon  may  flatter  himself 
that  he  has  done  his  duty.  I  feel  tempted  to  apply  to  this  indiscriminate 
and  senseless  mode  of  practice  the  adjective  which,  in  Latin,  is  given  to 
the  "lapis"  em[)loyed! 

The  stick  nitrate  of  silver  is  capable  of  destroying  a  chancroid  only  in 
the  very  earliest  stage  of  its  development,  and  even  then  cannot  be  relied 
upon  witli  the  same  certainty  as  the  stronger  caustics.  Still  it  has  been 
used  with  success  by  Kicord  and  others  for  the  destruction  of  the  sore 
resulting  from  a  successful  artificial  inoculation.  If  employed  for  this 
purpose,  the  epidermis  covering  the  pustule  should  be  removed,  and  the 
cavity  thoroughly  cleansed  of  its  secretion.  A  sharpened  crayon  of  the 
nitrate  should  then  be  bored  into  the  surface  of  the  underlying  ulcer,  or 
a  small  fragment  from  the  extremity  of  the  crayon  be  broken  off  and  be 
fastened  in  place  by  means  of  a  strip  of  adhesive  plaster.  This  dressing 
may  be  removed  at  the  end  of  forty-eight  hours,  and  the  wound  be  subse- 
quently protected  by  plaster  or  a  bandage. 

Of  the  strong  caustics  which  are  of  more  general  application,  the  most 
noteworthy  are  the  sulphuric  and  nitric  acids,  chloride  of  zinc,  Vienna 
paste,  the  pernitrate  of  mercury,  and  the  actual  cautery. 

Of  these,  frequent  trials  have  led  me  to  give  the  preference  to  sulphuric 
acid,  in  the  combination  which  has  been  so  higldy  recommended  by  Kicord, 
C'ullerier,  and  others,  and  which  is  known  as  the  "  carbo-sulphuric  [)aste." 
This  paste  is  easily  prepared  by  simply  saturating  willow  charcoal  with 
strong  sulphuric  acid.  The  ingredients  should  be  mixed  in  a  glass-stop- 
pered bottle,,  wliich  should  be  kept  standing  in  a  tumbler  to  receive  the 
moisture  \vhich  is  apt  to  collect  around  tlie  stopper  and  flow  over  upon  the 
sides  of  the  bottle.  The  paste  is  to  be  applied  by  means  of  a  glass  rod, 
or  a  glazed  crockery  spatula.  The  advantages  of  this  paste  are  the  facility 
with  wliich  it  enters  every  nook  and  crevice  of  the  ulcer,  the  thorough- 


368  CHANCROID. 

ness  with  which  it  does  its  work,  and  especially  the  fact  that  it  forms  a 
dry  scab,  which,  together  with  the  slough  beneath,  is  very  adherent,  and 
often  remains  until  the  sore  is  nearly  healed.  Meanwhile,  the  secretion  is 
so  diminished  that  the  dressings  require  but  infrequent  changes,  and  the 
danger  of  successive  inoculations  in  the  neighborhood  is  materially  lessened. 
The  chief  objection  to  it  is  the  pain  produced  by  its  application,  which  is 
decidedly  greater  than  that  from  nitric  acid.  A  patient  who  had  recently 
tried  both  at  a  short  interval,  told  me  he  tiiought  "  the  paste  hurt  him 
eight  or  ten  times  as  much  as  the  acid,"  but  the  former  accomplished  what 
the  latter  had  failed  to  do. 

Nitric  acid  is  preferably  applied  by  means  of  a  glass  rod  with  a  rounded 
extremity;  a  "drop  bottle,"  with  a  tapering  glass  stopper,  the  point  of 
which  extends  nearly  to  the  bottom  of  the  flask,  is  still  more  convenient ; 
but  a  simple  piece  of  wood,  as  an  ordinary  lucifer  match,  will  answer. 
Brushes  of  fine  glass  are  objectionable,  since  the  filaments  are  liable  to 
break  off  upon  the  surface  of  the  sore  and  excite  irritation.  The  pain  is 
for  an  instant  severe  when  the  acid  first  touches  the  ulcer,  but  becomes 
much  less  acute. on  subsequent  applications,  of  which  there  should  be 
several  in  order  to  render  tlie  destruction  com|)lete.  I  usually  occupy 
several  minutes  in  making  these  applications,  watching  the  effect  produced, 
and  judging  by  the  changes  which  take  place  in  the  tissues  when  enough 
has  been  applied.  Any  residue  should  be  carefully  removed  or  neutralized 
by  an  alkali,  and  the  neighboring  surfaces  be  protected  from  contact  by 
the  interposition  of  dry  lint.  A  water  dressing  may  be  substituted  as  soon 
as  suppuration  takes  place. 

The  liquor  hydrargyri  pernitratis  may  be  applied  in  a  similar  manner  ; 
I  am  not  aware,  however,  that  it  possesses  any  advantages  over  nitric  acid, 
and  it  is  attended  with  some  danger  of  producing  salivation  or  even  alarming 
symptoms  of  mercurial  poisoning,  although  the  surface  to  which  it  was 
applied  may  have  been  quite  small  in  extent.  Such  an  occurrence  is  rare, 
but  none  the  less  to  be  avoided,  as  may  be  seen  from  a  case  reported  in 
the  London  Lancet  for  Jan.  3,  1874,  p.  4L 

Potassa  cum  calce  made  into  a  paste  and  spread  upon  the  chancroid, 
where  it  is  allowed  to  remain  from  five  to  fifteen  minutes,  is  another  con- 
venient means  of  applying  the  destructive  method. 

A  valuable  caustic,  judging  from  the  high  encomiums  bestowed  upon  it 
by  many  French  surgeons,  especially  of  the  Lyons  School,  is  to  be  found 
in  "Canquoin's  paste,"  composed  of  equal  parts  of  chloride  of  zinc  and 
flour,  which  was  first  recommended  for  the  destruction  of  the  chancroid 
by  MM.  Rollet  and  Diday. 

The  use  of  the  actual  cautery  in  the  treatment  of  chancroids  had  been 
almost  abandoned,  when  it  was  recently  revived  by  Dr.  Henry  G.  Piflard,^ 
of  New  York,  who  employs  a  piece  of  platinum  wire  bent  upon  itself  and 
brought  to  a  white  heat  by  a  small  galvano-cautery  battery.  In  seven 
cases  to  which  it  was  applied  at  the  Charity  Hosj)it;»l,  the  duration  of  the 

'  Archives  of  Clinical  Surgery,  Nov.  1876. 


LOCAL    APPLICATIONS.  869 

lesion  varying  from  a  few  days  to  several  months,  the  average  time  re- 
quired for  the  healing  of  the  sores  is  said  to  have  been  eleven  and  a  half 
days — surely  a  very  satisfactory  result.  Paquelin's  thermo-cautery  is  also 
a  convenient  apparatus  for  the  ])urpose. 

Local  Applications As  already  remarked,  most  chancroids  will  heal 

under  attention  to  cleanliness  and  suitable  local  applications  and  dressings. 

A  point  of  no  little  importance  is  to  place  the  ulcer  under  such  condi- 
tions as  to  favor  a  return  of  blood  from  the  part.  Thus,  if  it  be  seated  on 
the  genitals,  and  especially  if  it  be  of  considerable  size,  it  will  be  well  to 
keep  the  patient  in  the  recumbent  posture  with  the  hips  elevated  by  means 
of  a  pillow.  If  it  be  on  the  penis,  this  organ  should  be  kept  elevated  upon 
the  abdomen  both  during  day  and  night.  Friction  of  the  clothes  and 
nocturnal  erections  should,  if  possible,  be  avoided. 

It  is  evident  that  the  form  of  dressing  must  vary  with  the  situation  of 
the  sore.  If  the  latter  is  seated  between  two  opposed,  layers  of  mucous 
membrane,  as  in  the  balano-preputial  fold  or  within  tlie  vulva,  a  dry 
dressing  will  be  the  best,  and  will  be  kept  sufficiently  moist  by  the  secre- 
tion of  the  part.  If  the  sore  is  upon  the  external  integument,  the  di'essing 
must  be  kept  wet,  otherwise  it  will  adhere  to  the  surface ;  the  patient  will 
shrink  from  changing  it  as  often  as  is  necessary ;  and  the  violence  done 
to  the  ulcer  by  its  removal  will  open  new  fissures  to  be  inoculated  by  the 
virus. 

The  advantages  of  dry  lint  are  not  generally  appreciated.  There  is  no 
better  dressing  for  most  chancroids  situated  upon  mucous  membranes. 
Obtain  the  ''  patent  lint"  so  called,  and  tear  it  into  shreds :  place  a  mass 
of  this  charpie  over  the  ulcer  and  draw  the  opposite  fold  of  mucous  mem- 
brane over  it.  The  "  pre])ared  absorbent  cotton,"  now  obtainable  of  drug- 
gists, is  also  excellent.  The  sore  is  thus  isolated,  and  the  lint  absorbs  the 
discharge  as  fast  as  it  is  secreted  ;  of  course  the  dressing  should  be  changed 
before  it  becomes  soaked.  The  only  obstacle  in  the  way  of  this  form  of 
dressing  is  the  false  idea  of  the  patient  that  some  "  wash"  is  required. 

Patients  often  inquire  whether  they  should  cleanse  the  sore  at  the  time 
of  changing  the  dressing.  I  commonly  tell  them  that  it  is  better,  with  a 
piece  of  soft  lint  and  without  friction,  to  absorb  any  moisture  or  discharge 
upon  the  surface  around  the  sore,  but  to  let  the  sore  itself  alone.  If  the 
dressing  is  changed  with  sufficient  frequency,  the  ulcer  will  not  require 
any  extra  cleansing. 

With  chancroids  upon  the  external  integument  we  must  use  some  lotion 
to  keep  the  lint  moist ;  but  this  object  is  attained  with  much  greater  ease 
in  some  situations  than  in  others.  If  the  sore  is  on  the  body  of  the  penis, 
it  is  easily  covered  with  a  fragment  of  lint  soaked  with  whatever  lotion  is 
employed ;  a  narrow  strip  of  rag  moistened  with  water  is  then  wound 
around  the  organ,  a  similar  strip  of  oiled  silk  is  added,  and  the  whole 
retained  in.  place  by  a  double-tailed  bandage.  With  chancroids  upon  the 
margin  of  the  prepuce  the  dressing  is  apt  to  slip  off,  but  may  be  kept  in  . 
place  by  means  of  an  ordinary  condom.  With  sores  upon  the  external 
24 


3t0  CHANCROID. 

surface  of  the  labia  majora,  upon  the  perinaeum  in  both  sexes,  etc.,  the 

ingenuity  of  the  surgeon  may  be  taxed  to  keep  them  moist  and  clean. 

As  a  local  application  to  tlie  surface  of  tlie  ulcer,  nothing  has  been  found 

equal  to  iodoform.     It  acts  as  a  sedative  to  relieve  pain  and  irritation,  and, 

o^  still  greater  importance,  it  clears  off  the  sloughy  surface  of  the  sore  and 

covers  it  with  "  healthy"  granulations.     It  should  be  reduced  to  a  fine 

powder  by  trituration,  either  with  or  without  the  addition  of  an  equal 

quantity  of  sugar  of  milk,  which  facilitates  its  minute  subdivision,  and  be 

sprinkled  at  each  dressing  over  the  surface  of  the  sore,  until  the  latter  has 

assumed  a  granulating  appearance,  when  it  should  be  omitted.     Still  more 

convenient  is  a  solution  of  iodoform  in  ether,  one-half  drachm  or  a  drachm 

of  iodoform  to  an  ounce  of  ether  (which  partially  removes  the  unpleasant 

odor).     This  is  to  be  painted  over  the  ulcer  with  a  camel's  hair  brush. 

The  ether  evaporates,  and  leaves  a  thin  yellowish  pellicle  of  iodoform  on 

the  surface.      Dr.  John  Ashhurst,  Jr.,  recommends  it  in  the  following 

form : — 

^.     lodoformi  5ss 2 

Glycerinje  ^v] 30 

Spt.  Villi  Rect.  3ij 8 

M. 

The  only  objection  to  the  use  of  iodoform  is  its  bad  odor,  but  this  must 
be  endured  for  the  sake  of  the  benefit  it  affords.  I  have  tried  it  with  the 
addition  of  an  equal  part  of  tannin,  as  recommended  by  Dr.  Cole,  of  Hot 
Springs,  Ark.  This  mixture  is  indeed  much  less  odorous,  but  it  cakes 
on  the  surface  of  the  sore  and  does  not  act  well.  In  the  following  pre- 
paration the  smell  of  iodoform  is  almost  entirely  masked : — 


I^.     lodoformi  ^ss        2 

Ung.  Petrolei  gj        30 

01.  Meiitli.  Pip.  gtt.  vj 

M. 


40 


"W  hen  the  objection  to  the  smell  of  iodoform  is  insuperable,  I  order  :- 

GO 


I^.     Hydrarg.  Chloridi  Mitis  3ij    .     .     .     .  8 

Hydrarg.  Protiodidi  ^ij 2 

CretiB  Precip.  §j 30 

M. 


Whichever  of  these  applications  has  been  made,  the  subsequent  dressing 
is  to  be  applied  according  to  the  rules  above  given — dry  lint  to  chancroids 
situated  on  moist  mucous  membranes;  wet  lint  covered  with  oil-silk  to 
those  on  external  surfaces. 

Next  to  iodoform,  a  solution  of  the  nitrate  of  silver,  about  fifteen  grains 
to  the  ounce,  is  probably  the  best  application,  the  lint  which  is  to  be  placed 
upon  the  sore  having  first  been  soaked  in  it.  Other  formulae  are  as  fol- 
lows : — 

R.     Acidi  Carbolici  5i-ij 4] — 8| 

Aquifi  Oj 5001 

M. 


LOCAL    APPLICATIONS.  371 

I^.     Balsam.  Peruvian.  ,^ss 15! 

Argent.  Nit.  Cryst.  vel 

Cupri  Sulphat,  gr.  iij |20 

M.  (Zeissl.) 

I^.     Ferri  Potassio-tart.  §ss 151 

Accuse  §vj         180| 

M.  (Ricord.) 

R.     Acidi  Tannici  9j 130 

Aquse  Jvj 180 

M. 

I^.     Liquoris  Sod;B  Chlorinatre  3.1     ••     ■         41 

A(|use  Purfe§ij 60| 

M. 

I^.     Acidi  Nitrici  Diluti  Jj 4| 

Aquc-e  Purse  3viij 250] 

M. 

^..      Vini  Aromatici  §j 301 

Aquae  §iij 90 1 

M. 

A  formula  for  a  convenient  substitute  for  the  French  aromatic  wine  may 
be  found  on  page  204.  The  strength  of  these  lotions  must  be  adapted  to 
the  sensibility  of  the  part,  which  varies  in  different  cases.  They  should 
never  be  so  strong  as  to  excite  pain  or  produce  irritation. 

The  black  wash,  composed  of  from  one  to  three  scruples  of  calomel  to 
four  ounces  of  lime-water,  is  a  favorite  application  with  many  surgeons. 
The  dark-colored  sediment  in  this  mixture  is  an  oxide  of  mercury,  and  is 
inert  unless  it  aifords  mechanical  protection  to  the  sore.  In  my  opinion, 
black  wash  is  a  less  cleanly  and  less  desirable  lotion  than  those  before 
mentioned.  A  solution  of  the  disulphate  of  quinine  (gr.  j  ad  ^j)  with  just 
enough  dilute  sulphuric  acid  to  dissolve  it  is  recommended  by  Mr.  Nunn 
(London  Lancet). 

A  fact  too  little  known,  or  too  little  appreciated  by  the  profession,  is 
that  ointments  of  whatever  kind  are  not  only  useless  but  positively  inju- 
rious on  account  of  their  tendency  to  become  rancid.  They  should  never 
be  employed  unless,  from  the  position  of  the  sore,  or  from  the  necessarily 
long  intervals  between  the  dressings — as  at  night  or  during  a  journey — 
the  evaporation  of  a  water  dressing  cannot  be  prevented,  even  with  the 
assistance  of  oiled  silk  and  glycerine. 

Mercurial  ointment,  although  very  commonly  used  in  Sigmund's  wards 

in  Vienna,  is,  in  my  opinion,  especially  objectionable.     Zeissl  also  regards 

it  with  disfavor,  and  prefers  the  glycerite  of  starch.     One  of  the  following 

formuliie  may  be  used  in  the  rare  instances  in  which  an  unctuous  dressing 

is  required  : — 

R.      Ung.  Petrolei  §i 30 

Tincturre  Opii  5j 4 

t  Caloraelanos  gr.  xxxvj      ....  2  35 

M. 

R.     Balsarai  Peruviani, 

0!ei  Ricini,  aa  §j 30| 

M. 


312  CHANCROID. 

R.     Ung.  Petrolci  gj 30! 

Pulv.  Opii  5j     • 4' 

M. 

Before  one  dressinjij  is  soaked  with  the  discharge,  another  should  be 
substituted.  If  the  first  adhere  to  the  surface,  it  should  be  carefully  moist- 
ened before  attem[)ting  its  removal,  in  order  to  avoid  any  abrasion,  which, 
by  subsequent  inoculation,  would  increase  tlie  size  of  the  sore.  The  dress- 
ing of  most  uncomplicated  chancroids  need  be  renewed  only  two  or  three 
times  a  day,  but  phagedenic  ulcers  require  a  much  greater  frequency. 

During  the  progress  of  cicatrization,  exuberant  granulations  may  spring 
up  and  require  repression  by  pencilling  with  a  crayon  of  nitrate  of  silver. 
A  superficial  application  of  this  agent  is  also  beneficial  in  relieving  the 
irritability  and  pain  of  some  ulcers  in  the  progressive  and  stationary 
periods. 

Other  applications  than  those  now  mentioned  may  be  required.  For 
instance,  in  chancroids  attended  by  much  inflammation,  leeches  to  the 
groins  or  perineum,  and  poultices  or  sedative  lotions,  may  be  of  service. 
Pain  should  be  relieved  by  the  exhibition  of  opium  in  large  doses  internally, 
and  by  its  application  externally. 


CHANCROIDS    OF    THE    FR^NUM.  31; 


CHAPTER    II. 

PECULIARITIES    DEPENDENT    UPON    THE    SEAT 
OF    CHANCROIDS. 

The  seat  of  a  chancroid  often  modifies  the  symptoms  and  necessitates 
clianges  in  the  treatment. 

Chancroids  upon  the  Integument  of  the  Penis The  majority 

of  venereal  ulcerations  following  suspicious  connection,  and  seated  upon 
the  integument  of  the  penis,  are  chancres  and  not  chancroids  ;  why,  I 
do  not  know  ;  but  it  behooves  the  surgeon  to  look  sharply  to  his  diagnosis 
with  ulcers  in  this  region.  The  rule  is  far  from  being  invariable,  for  I 
have  met  with  many  cases  of  simple  chancres  situated  between  the  pre- 
putial orifice  and  the  root  of  the  penis  and  even  upon  the  pubes.  Chan- 
croids upon  the  integument  of  the  penis  often  originate  in  a  follicle,  and 
when  first  noticed  resemble  a  pustule  or  small  abscess  {follicular  chan- 
croids, see  p.  358).  Not  unfrequently  they  extend  to  the  loose  cellular 
tissue,  and  undermine  the  skin  around  a  small  external  opening  through 
which  the  pus  can  be  made  to  well  up  on  pressure.  The  mobility  of  the 
integument  over  the  concealed  chancroidal  cavity  interferes  with  cicatri- 
zation and  prolongs  the  duration  of  the  ulcer.  The  cavity,  first,  thor- 
oughly cleansed  of  matter,  should  be  cauterized  by  means  of  a  sliver  of 
wood  (as  a  lucifer  match)  dipped  in  strong  nitric  acid ;  or  sometimes  it 
becomes  necessary  to  enlarge  the  external  opening  even  at  the  risk  of 
inoculation  of  the  edges  of  the  wound.  The  ulcer  having  been  thoroughly 
exposed  and  freely  cauterized,  should  be  kept  moist  by  the  application  of 
wet  lint,  a  layer  of  oiled  silk,  and  a  retentive  bandage,  in  the  manner 
previously  indicated. 

Chancroids  of  the  Fr.enum Chancroids  of  the  fra-num  are  espe- 
cially painful,  persistent  and  exposed  to  hemorrhage.  They  may  com- 
mence either  upon  the  free  margin  or  at  the  base  of  the  bridle.  In 
the  former  case  a  rent  or  fissure,  the  result  of  violence  during  coitus,  has 
probably  been  inoculated  ;  and  the  resultant  chancroid  gradually  eats 
away  the  whole  bridle,  and  hollows  out  a  narrow  longitudinal  groove  upon 
the  under  surface  of  the  glans,  giving  great  annoyance,  long  persisting, 
and  resistirtg  ordinary  modes  of  treatment.  Again,  they  may  proceed  from 
chancroids  in  the  neighborhood,  which  exhibit  a  remarkable  tendency  to 
involve  the  bridle,  if  situated  near  it.  In  this  case  the  base  of  the  fraMium 
is  first  attacked  and  often  becomes  perforated  from  side  to  side  ;  the  chan- 


374  CHANCROID. 

croidal  opening  gradually  enlarges,  extends  to  the  free  margin,  and,  as  in 
the  former  case,  probably  destroys  the  whole  bridle.  The  frtenum  is  copi- 
ously supplied  with  blood  and  exceedingly  sensitive  ;  hence,  ulcers  of  this 
part  are  very  liable  to  bleed  and  give  rise  to  much  suffering.  Their  per- 
sistency and  destructive  tendency  are  due  to  the  frequent  rupture  of  the 
longitudinal  fibres  of  the  framum,  occasioned  by  the  constant  motion  to 
which  it  is  exposed,  in  walking,  handling  the  penis  during  micturition, 
in  erections,  etc.  Minute  rents  are  thus  caused  in  the  sore  which  become 
inoculated  and  increase  its  depth  ;  and  ulcerative  action  goes  on  until  the 
whole  bridle  is  destroyed,  including  the  portion  buried  in  the  under  sur- 
face of  the  glans  ;  and  hence  the  fossa  already  referred  to.  Occasionally 
they  extend  to  the  urethra  and  give  rise  to  a  urinary  fistula.  In  the  treat- 
ment of  these  ulcers,  the  patient  should  be  directed  to  avoid  all  motion 
of  the  part  which  will  stretch  the  fra;num  ;  the  glans  should  not  be  un- 
covered except  to  dress  the  sore,  and  even  then  no  further  than  is  abso- 
lutely necessary  to  insert  the  dressing.  If  the  chancroid  threaten  to  de- 
stroy the  whole  bridle,  time  will  be  gained  by  accomplishing  the  same  at 
once  by  means  of  caustic.  When  perforation  has  taken  place,  the  remain- 
ing portion  of  the  bridle  should  be  divided  with  scissors,  and  the  raw  sur- 
faces freely  cauterized.  The  flow  of  blood  in  this  operation  is  often  trou- 
blesome, and  should  be  avoided  by  previously  passing  a  double  ligature 
through  the  opening  and  tying  a  thread  at  either  extremity  of  the  fra^num, 
all  of  which  should  be  removed.  Diday  heats  one  blade  of  a  dull  pair  of 
scissors  over  a-spirit  lamp,  and" passing  the  opposite  cold  blade  through 
the  opening  to  serve  as  a  support,  thus  divides  the  froanum  by  the  actual 
cautery.^  The  galvano-caustic  wire  would  seem  well  adapted  to  this  pur- 
pose. 

SuB-PREPUTiAL   CHANCROIDS Thesc  are  almost  always   multiple ; 

they  suppurate  freely  and  are  quite  destructive  in  their  tendency.  Thi'ee 
conditions  of  the  prepuce  may  obtain  : — 

1.  This  envelope  may  be  so  large  as  to  be  readily  retracted. 

2.  Tiie  prepuce  may  be  naturally  tight,  or  it  may  be  edematous  from 
attendant  inflammation,  so  that  the  sores  are  with  difficulty  exposed,  and 
the  attempt  occasions  rents  in  their  surface,  and  considerable  pain  to  the 
patient. 

3.  There  may  be  complete  phimosis,  eitlier  congenital  or  supervening 
as  a  complication  of  the  disease. 

In  the  last  case,  the  sores  are  more  effectually  "  concealed"  than  if 
situated  within  the  urethra  or  vagina,  and,  indeed,  cannot  be  exposed  at 
all  except  by  an  o[)eration.  The  discharge  which  collects  in  the  balano- 
preputial  fold  before  escaping  from  the  or i rice,  may  usually  be  distinguished 
from  that  of  balanitis.  It  is  of  a  different  color  and  less  homogeneous, 
and  is  often  streaked  with  blood  and  mingled  with  organic  detritus.     The 

•  Du  chancro  primitif  du  frein  cle  la  verge;  Gaz.  liebd.  de  mdd.,  Par.,  Oct.  19, 
1855,  p.  749. 


SUB-PREPUTIAL    CHANCROIDS.  375 

exact  situation  of  the  ulcers  may  sometimes  be  detected  by  palpation, 
whenever  the  inflammation  of  the  surrounding  tissues  is  sufficient  to  con- 
vey the  impression  of  hardness  to  the  fingers  applied  to  the  external  surface 
of  the  prepuce,  and  also  by  the  pain  excited  by  pressure. 

Chancroids  are  apt  to  appear  upon  the  margin  of  the  preputial  orifice  in 
consequence  of  successive  inoculation  from  the  discharge  of  those  within, 
and  they  present  a  few  peculiarities  worthy  of  notice.  Thus  they  are 
often  extilcerous,  or  superficial,  their  floor  being  nearly  or  quite  on  a  level 
with  the  surrounding  integument,  a  fact,  which  has  been  attributed  to  the 
constant  irritation  to  which  they  are  subjected  from  the  sub-preputial  dis- 
charge and  the  urine.  The  same  cause  frequently  occasions  a  fictitious 
indui'ation  of  their  base,  so  that  they  may  be  mistaken  for  true  chancres. 
They  sometimes  appear  as  rents  or  fissures  in  consequence  of  their  occu- 
pying the  folds  of  the  orifice,  and  they  are  then,  as  it  were,  doubled  upon 
themselves,  so  that  two  jwrtions  of  their  surface  are  in  apposition.  Any 
attempt  to  destroy  them  by  cauterization  will  fail,  so  long  as  the  ulcers 
beneath  the  prepuce  remain  open  and  secrete  inoculable  pus. 

Sub-preputial  chancroids  ai"e  especially  exposed  to  become  complicated 
with  balanitis,  abscesses  between  the  two  layers  of  the  prepuce,  phagedtena, 
and  gangrene.  Several  neighboring  ulcerations  may  unite  and  form  a 
large  sore,  which  may  result  in  the  destruction  of  more  or  less  of  the 
glans,  or,  by  extending  along  the  furrow  at  its  base,  nearly  enucleate  this 
organ. 

The  treatment  varies  according  to  the  presence  or  absence  of  phimosis. 
When  the  prepuce  can  be  kept  retracted  without  becoming  oademcitous, 
and  incurring  danger  of  paraphimosis,  the  ulcers  may  be  cauterized  and 
dressed  like  chancroids  upon  the  external  integument  of  the  penis.  They 
will  thus  heal  much  more  readily  than  if  the  prepuce  be  kept  forward. 

In  cases  of  partial  phimosis,  in  Avhich  retraction  of  the  prepuce  can  be 
effected  only  with  pain  and  violence,  it  is  better  to  allow  it  to  remain  for- 
ward and  treat  the  ulcers  as  if  the  phimosis  were  complete.  Destructive 
cauterization  is  here,  of  course,  impossible,  and  attention  to  cleanliness,  the 
use  of  astringent  lotions,  and  in  cases  attended  with  inflammation,  hot  hip- 
baths and  rest  are  the  only  means  of  relief.  The  balano-preputial  fold 
should  be  thoroughly  cleansed  with  injections  of  tepid  water,  repeated  from 
three  to  six  times  a  day,  according  to  the  copiousness  of  the  discharge  by 
means  of  a  syringe  with  a  nozzle  long  enough  to  reach  the  base  of  the 
glans.  An  astringent  or  slightly  caustic  lotion  may  afterwards  be  thrown 
in  ;  one  of  the  best  for  the  purpose  is  a  solution  of  nitrate  of  silver,  from 
five  to  ten  grains  to  the  ounce  of  water.  Tliis  application  is  not  contra- 
indicated  even  by  the  presence  of  inflammation,  since  its  effect  is  found  to 
be  sedative.  Abscesses  occurring  between  the  layers  of  the  prepuce  must 
be  opened. 

The  reader  is  referred  to  Chaps.  III.  and  IV.,  of  Part  I.  of  this  work 
for  a  fuller  account  of  the  treatment  of  balanitis  and  phimosis  complicating 
the  chancroid. 

Sub-preputial   chancroids,  especially  when  accompanied  by  chancroids 


376  CHANCROID. 

of  the  preputial  orifice,  are  often  followed  by  such  an  amount  of  permanent 
contraction  of  the  prepuce  as  to  render  exposure  of  the  glans  difficult  or 
impossible.  In  these  cases  it  is  better,  after  the  sores  have  healed,  to  resort 
to  circumcision,  otherwise  the  abnormal  condition  of  tlie  parts  is  a  constant 
source  of  annoyance,  interfering  with  cleanliness  and  exposing  to  repeated 
attacks  of  balanitis  and  herpes. 

Urethral  Chancroids — Chancroids  are  not  unfrequently  met  with 
at  the  meatus,  occupying  either  a  portion  or  the  whole  of  the  margin  of 
this  orifice,  and  they  occasionally  occur  within  the  fossa  navicularis,  which 
is  richly  supplied  with  follicles  whose  moutlis  afford  ready  entrance  to 
the  poison.  In  this  manner  a  number  of  small  follicular  chancroids  may 
arise  in  the  fossa,  which  in  consequence  of  the  ulceration  of  the  intervening 
walls  subsequently  form  a  sore  of  considerable  size,  and  this  has  been  known 
to  extend  into  the  subcutaneous  cellular  tissue  and  undermine  the  integu- 
ment of  the  penis  even  up  to  the  pubes  (Zeissl). 

1  have  never  met  with  chancroids  in  any  deeper  portion  of  the  canal, 
and  the  possibility  of  their  existence  is  doubted  by  most  authorities  of  the 
present  day,  including  Zeissl.  Ilicord,'  indeed,  presented  to  the  Academy 
of  Medicine,  of  Paris,  two  specimens  of  ulcers  affecting  tiie  deeper  portions 
of  the  urethra  and  even  the  bladder,  of  which  he  has  given  plates  in  his 
Atlas,  and  in  his  Notes  to  Hunter  on  Venereal.  These  he  believed  to  be 
chancroids,  on  tlie  ground  that  he  had  successfully  inoculated  the  secretion 
coming  from  the  patient's  urethroe  before  death.  With  our  present  knowl- 
edo'e,  we  cannot  now  regard  this  proof  as  conclusive ;  and,  even  at  the 
meeting  of  the  Academy  referred  to,  a  number  of  the  members  present 
expressed  their  belief  that  the  ulcerations  were  tubercular.  We  conclude 
that  the  existence  of  uretliral  and  vesical  chancroids,  except  at  or  near  the 
meatus  urinarius,  is  not  proven.  A  case  of  tuberculosis  of  the  urethra 
simulating  urethral  chancre,  was  published  by  Emanuel  Soloweitschick  in 
the  Archiv  fiir  Derm,  and  Syph.,  vol.  ii,  p.  1. 

Any  lesion  confined  to  the  lips  of  tlie  meatus  is  of  course  visible  to  the 
unassisted  eye.  For  ex[)loration  of  the  fossa  navicularis,  Toynbee's  ear- 
specula  may  be  used,  the  uniform  calibre  of  which  permits  of  their  intro- 
duction for  about  an  inch,  and  if  the  patient  be  placed  in  direct  sunlight, 
or  reflected  light  be  used,  an  excellent  view  of  the  lining  membrane  for 
this  distance  may  be  obtained.  Any  short  endoscopic  tube,  will,  of  course, 
answer  the  same  purpose.  Dr.  T.  Skeene,  of  Brooklyn,  has  recently  in- 
vented one  (Fig.  113)  which  has  some  advantages. 

No  special  treatment,  other  than  that  described  in  the  previous  chapter, 
is  required.  The  dressing,  with  perhaps  a  thread  attached  to  facilitate 
its  withdrawal,  should  be  renewed  after  each  act  of  micturition.  If  con- 
tact of  the  urine  be  painful,  tliis  may  partially  be  relieved  by  holding  the 
penis  in  a  glassful  of  warm  water  during  the  act. 

These  ulcerations  may  eat  away  the  lips  on  either  side,  finally  leaving 
the  urethral  opening  funnel-form  in  shape.    Still  more  frequently  a  stricture 

'  Bull.  Acad,  de  Med.  1838,  t.  ii,  p.  506. 


CHANCROIDS    OF    FEMALE    GENITAL    ORGANS. 


377 


at  or  near  the  meatus  is  formed  during  the  process  of  cicatrization.     To 
prevent  this  a  pledget  of  lint  or  a  piece  of  a  bougie  about  an  inch  long, 


Fi.cr.  113. 


Skeene's  endoscope. 

smeared  with  some  ointment,  and  retained  in  place  by  an  appropriate 
bandage,  should  be  kept  in  the  canal  while  the  sore  is  healin"-.  Even 
with  this  precaution,  "  slitting  the  meatus"  will  often  be  required  subse- 
quently. 

Chancroids  of  the  Female  Genital  Organs. — Upon  the  external 
and  integumental  surface  of  the  labia  majora,  chancroids  often  assume  the 
appearance  of  pustules  or  abscesses,  in  consequence  of  the  virus  having 
inoculated  the  internal  surface  of  one  or  more  of  the  follicles  (follicular 
chancroids)  ;  and  there  is  frequently  more  or  less  oedema  of  the  subcuta- 
neous cellular  tissue,  as  evinced  by  the  swelling  and  hardness  of  the  labia. 
When  the  pustule  breaks,  the  underlying  ulcer,  if  exposed  to  the  air,  be- 
comes covered  with  a  scab  and  resembles  ecthyma. 

Chancroids  are  also  common  on  other  portions  of  the  vulva ;  on  the  in- 
ternal surface  of  the  labia  majora,  where  they  occasion  pain  and  difficulty 
in  walking  ;  on  the  labia  minora  ;  and  in  the  neighborhood  of  the  clitoris 
and  meatus.  Their  base  is  engorged  from  the  irritation  of  the  urine  and 
vaginal  discharges,  which  likewise  renders  them  difficult  of  cure.  Those 
situated  at  the  meatus  often  penetrate  the  urethra  for  some  distance,  giving 
the  orifice  an  infundibuliform  shape,  or,  by  destroying  the  posterior  wall  of 
the  canal,  throw  its  opening  backwards  into  the  vagina.  When  attacked 
by  phagediBna,  as  not  unfre(iiiently  happens,  the  loss  of  tissue  may  result 
in  great  deformity  and  inconvenience. 

Vulvar  chancroids  are,  however,  much  more  common  at  the  fourchette 
than  elsewhere,  partly  in  consequence  of  its  dependent  position  where  con- 
tagious secretions  gravitate,  and  partly  owing  to  the  rents  and  abrasions  to 
which  it  is  exposed  in  sexual  intercourse,  and  to  its  being  neglected  in  the 
ordinary  aftentions  to  cleanliness.  They  have  been  attributed  to  inocula- 
tion of  discharges  from  the  deeper  parts  of  the  vagina,  and  have  conse- 
quently been  regarded  as  affording  a  strong  probability  of  the  existence  of 
chancroids  upon  the  os  uteri.     These  ulcers  often  assume  the  form  of  fis- 


378  CHANCROID. 

sures,  like  chancroids  of  the  preputial  orifice  and  of  the  anus,  and  for  the 
same  reason. 

Examination  of  the  vulva  and  lower  part  of  the  vagina  is  greatly  facili- 
tated by  passing  one  finger  up  the  anus  and  pressing  the  recto-vaginal  wall 
forwards. 

Chanci'oids  often  occupy  the  interspaces  between  the  caruncles,  where 
they  may  readily  be  overlooked  unless  carefully  sought  for.  In  the  lower 
portion  of  the  vagina,  chancroids  are  generally  irregular  in  their  outline, 
and  often  invade  the  walls  of  this  passage  for  a  certain  distance  internally, 
and  the  vulva  externally.  Among  low  prostitutes  especially,  they  may 
open  a  communication  with  the  rectum,  forming  fistula?  which  are  difficult 
or  impossible  to  close  after  the  healing  of  the  sore.  I  am  informed  by  my 
friend,  Dr.  Emmet,  that  the  ordinary  operation  for  recto-vaginal  fistulsB, 
when  such  fistula?  were  due  to  venereal  ulcerations,  has  always  failed,  even 
in  his  skilful  hands.  As  we  ascend  the  vagina,  chancroids  are  less  fre- 
quently met  with.  They  are  least  uncommon  in  the  lower  third,  and  are 
exceedingly  rare  in  the  upper  two-thirds. 

They  are  oftener  seen  on  the  cervix  uteri,  but  their  occurrence  even 
here  is  a  rarity.  Among  332  cases  of  venereal  sores  of  the  female  genital 
organs,  including  both  cliancroids  and  true  chancres,  observed  by  Klink,^ 
eight  were  situated  on  the  cervix  and  one  on  the  deeper  portion  of  the 
vagina.  Klink  remarks  that  French  authorities  regard  their  existence 
upon  the  cervix  as  much  more  frequent  than  do  the  German  ;  while,  on 
the  other  hand,  the  French  look  upon  a  chancroid  of  the  upper  part  of  the 
vagina  as  an  extreme  rarity,  yet  the  Germans  think  it  not  of  such  very 
uncommon  occurrence.  He,  although  a  German,  thinks  the  French  are 
in  the  right. 

It  has  been  observed,  as  might  be  expected  a  priori^  that  in  chancres 
on  the  cervix,  the  contagion  was  often  derived  from  a  man  having  a  ^ore 
situated  on  the  glans  penis,  and  especially  at  the  meatus. 

These  ulcers  upon  the  cervix  may  be  single  or  multiple.  They  may 
occupy  one  or  both  lips  of  the  os,  or  involve  a  large  portion  of  the  cervix. 
They  occasion  little  or  no  pain.  Similar  sores  are  usually  present  at  the 
vulva.  They  are  commonly  accompanied  by  catarrhal  inflammation  of 
the  vagina,  often  by  inflammation  of  the  womb.  They  are  prone  to  take 
on  phagedenic  action  and  destroy  a  portion  or  the  whole  of  the  cervix ;  in 
one  case  mentioned  by  Bernutz^  pelvic  peritonitis  was  induced.  They 
may  extend  into  the  cervical  canal,  and,  according  to  Despres,^  even 
into  the  uterine  cavity.  When  seated  upon  the  margin  of  the  os  externum, 
their  cicati'ization  results  in  a  firm  stricture  of  this  orifice. 

Can  a  chancroid  exist  so  far  within  the  cervical  canal  as  not  to  be 
visible  and  not  to  present  any  evidence  of  its  presence  upon  vaginal  ex- 
amination with  a  speculum  ?     It  can,  if  we  may  credit  tlie  following  case  : — 

'  Vrtljschr.  f.  Dermat.,  Wieii,  1876,  p.  542. 

2  Traite  des  mal.  de.l'utefus,  t.  ii,  p.  ]17. 

3  Traitd  iconographique  de  rulceration  et  des  ulceres  du  col  de  I'uterus,  Paris, 

1870. 


CHANCROIDS    OF    FEMALE    GENITAL    ORGANS.  379 

"  In  March,  1840,  a  woman  from  the  neighborhood  of  Aries,  aged  22, 
and  remarkably  beautiful  in  form  and  appearance,  was  thoroughly  ex- 
amined in  the  usual  manner,  by  Prof.  Lallemand,  and  no  symptom  of 
venereal  disease  discovered.  This  examination  was  made  at  the  request 
of  an  officer  who  complained  that  she  had  infected  him ;  and  several  simi- 
lar complaints  being  subsequently  made  by  others,  she  was  sent  to  the 
police  station,  where  she  was  again  examined  by  M.  Delmas  in  the 
presence  of  a  considerable  number  of  students.  The  neck  of  the  uterus 
still  appeared  healthy,  but  on  pressing  it  with  the  speculum,  it  discharged 
a  muco-purulent  fluid,  which  was  inoculated  in  four  places  upon  the 
patient's  thigh,  ivitli  the  effect  of  producing  four  well-marked  chcciicroids."^ 

AVe  shall  see  hereafter  when  considering  the  true  chancre,  that  one  of 
its  most  prominent  symptoms,  viz.,  induration  of  its  base,  which  is  almost 
always  present  in  men,  is  often  poorly  marked  or  even  absent  in  women. 
It  may  hence  be  inferred  that  the  exact  diagnosis  of  venereal  ulcers  in 
women,  as  to  whether  they  are  chancroids  or  chancres,  is  frequently  diffi- 
cult or  even  impossible,  unless  indicated  by  the  condition  of  the  inguinal 
ganglia  or  the  occurrence  of  secondary  symptoms  at  the  usual  period. 
This  dithculty  is  increased  when  the  sore  is  situated  upon  the  cervix,  since 
the  normal  consistency  of  this  part  is  so  great  as  readily  to  mask  to  the 
touch  any  induration,  especially  of  the  parchment  form,  of- the  base  of  the 
ulcer. 

The  treatment  of  chancroids  of  the  female  genital  organs  does  not  differ 
materially  from  that  already  laid  down.  The  application  of  the  speculum 
to  venereal  diseases,  introduced  by  Ricord,  has  rendered  these  ulcers 
nearly  as  accessible  as  if  situated  upon  the  external  integument.  Almost 
the  only  modifications  requii'ed  in  the  treatment  are  due  to  the  difficulty  of 
maintaining  and  changing  with  sufficient  frequency  the  local  dressing,  and 
to  the  danger  in  certain  regions  of  resorting  to  destructive  cauterization. 

With  chancroids  about  the  vulva  the  stronger  caustics  may  be  used  with 
the  same  freedom  and  the  same  benefit  as  in  the  male  sex.  It  requires  no 
little  care  and  attention  to  keep  the  di'essing  in  such  immediate  contact 
with  the  sore  as  to  be  of  any  service,  but  this  may  still  be  accomplished 
by  means  of  a  T  bandage,  or  by  the  ingenious  contrivance  with  regard  to 
which  women  beyond  the  age  of  puberty  need  no  instruction.  Here,  as 
elsewhere  upon  the  female  genital  organs,  the  dressing  soon  becomes 
soaked  with  the  natural  or  abnormal  secretion  of  the  parts,  and  requires 
more  frequent  changing  than  in  the  male. 

With  chancroids  situated  upon  the  walls  of  the  vagina,  destructive 
cauterization  should  be  used  with  great  caution,  for  fear  of  opening  com- 
munication with  the  rectum,  urethra,  or  bladder,  or  in  the  deeper  portion 
of  this  passage,  of  inducing  peritonitis.  This  objection  does  not  apply  to 
chancroids  of  the  cervix,  which  may  be  tiioronghly  cauterized  through  a 
speculum.  If  the  patient  can  be  seen  often  enougli,  the  sore  may  be  iso- 
lated and  its  secretion  absorbed  by  the  insertion  of  a  tampon  of  lint  either 

•  J.  Soc.  de  m6d.  prat,  de  Montpel.,  1845  ;  and  Gaz.  m6d.  de  Paris,  1845,  p.  670. 


380  CHANCROID. 

dry  or  medicated ;  but  this  requires  a  visit  at  least  once  in  twenty-four 
hours,  and  may,  tlierefore,  be  impracticable  in  private  practice.  The  best 
substitute  is  the  frequent  use  by  the  patient  herself  of  copious  vaginal  in- 
jections, either  disinfectant  or  astringent,  as  a  solution  of  carbolic  acid, 
nitrate  of  silver,  alum,  tannin,  etc. 

Chronic  Chancroid  of  Prostitutes — Among  public  Avomen,  especially 
those  of  the  lowest  class,  there  is  a  form  of  chancroid  which  is  often  seen 
in  our  public  hospitals,  and  which  is  entitled  to  be  regarded  as  a  variety 
of  the  simple  chancre.  Examples  of  it  are  always  to  be  found  in  the 
venereal  wards  of  Charity  Hospital,  Blackwell's  Island.  It  was  first 
noticed  by  MM.  Boys  de  Loury  and  Costilhes,^  and  more  recently  by 
Rollet,*"  of  Lyons,  who  speaks  of  it  under  the  head  of  phagedena,  and 
whose  description  I  shall  chiefly  follow. 

"  Chronic  chancroids  may  be  seated  upon  any  portion  of  the  genital 
organs,  but  especially  at  the  posterior  commissure  of  the  labia  majora. 
There  is  also  another  point  where  they  are  very  frequent,  viz.,  at  the 
entrance  of  the  vagina,  on  either  side  of  the  urethra,  in  the  furrow  exter- 
nal to  this  canal.  These  ulcers  often  acquire  a  considerable  size,  less, 
however,  than  serpiginous  chancroids,  whose  progress  is  always  more 
rapid.  In  most  cases,  no  difference  can  be  recognized  between  the  appear- 
ance of  a  chronic  chancroid  and  a  chancroid  of  the  ordinary  type  ;  but  it 
is  found  on  inquiry  that  the  ulceration  has  persisted  for  an  unusually 
long  time,  and  that  it  is  indolent — a  character,  however,  which  must  not 
be  regarded  as  belonging  exclusively  to  this  variety,  since  an  acute  chan- 
croid, occupying  the  mucous  membrane  of  the  vagina,  is  often  free  from 
pain.  Yet  we  find  women  with  chronic  chancroids  of  the  genital  organs 
either  multiple  or  of  large  extent,  the  existence  of  which  they  do  not  even 
suspect,  since  they  experience  no  inconvenience  from  them. 

"There  is  rarely  any  inflammation,  but  usually  an  infiltration  of  thg  sur- 
rounding tissues.  The  surface  of  the  ulcer  is  of  a  pale  color,  and  often 
covered  with  a  somewhat  firm  secretion,  beneath  which  the  tissues  are 
also  hardened  ;  hence  the  name  given  them  by  M.  S{)erino  of  callous  and 
chronic  vulvo -vaginal  chancres.  This  variety  is  usually  met  with  in 
women  from  thirty  to  forty  years  of  age,  who  are  debilitated,  of  a  pallid 
complexion,  and  exhausted  by  their  excesses." 

M.  Rollet  thinks,  with  reason,  that  other  affections  than  chancroids 
have  been  included  under  this  name  ;  for  instance,  that  a  mere  rent  in  a 
debilitated  subject  may  terminate  in  a  chronic  ulcer  under  the  irritation  of 
filth,  contact  of  the  urine  and  vaginal  secretion,  and  frequent  indulgence 
in  sexual  intercourse. 

The  callous  condition  of  the  surrounding  tissues  has  appeared  to  me  to 
be  the  greatest  obstacle  in  the  way  of  their  cure.  I  have  treated  them 
successfully  at   Cliarity  Hospital,  when   their  situation,  as  in  the  furrow 

'  Des  ulcerations  chroniquos,  ou  chancres  clironiqiies  des  parties  geni tales  de 
la  femrae.     Paris,  1845. 

2  Traite  des  mal.  veil.,  Paris,  18G5,  p.  186. 


CHANCROIDS    OF    THE    ANUS    AND    RECTUM.  381 

between  the  nates,  permitted ;  by  putting  the  patient  under  the  influence 
of  ether,  excising  the  hardened  and  hypertrophied  masses  of  tissue,  and 
freely  applying  the  actual  cautery  to  the  fresh  wound  as  well  as  to  the  sur- 
face of  the  ulcer.  But  there  are  other  cases  at  the  above-named  institu- 
tion, in  which  the  situation  of  the  sore  at  the  entrance  of  the  vagina  does 
not  admit  of  such  heroic  treatment,  and  in  which  the  patients  make  their 
appearance  from  time  to  time  during  a  period  of  years,  leaving  the  hospital 
whenever  they  are  somewhat  improved,  and  returning  when  their  condi- 
tion is  again  so  aggravated  that  they  cannot  carry  on  their  trade.  In 
many  such  cases,  powdering  the  surface  of  the  ulcer  several  times  a  day 
with  iodoform  or  with  the  persulphate  of  iron  (Monsel's  salt)  will  be  found 
to  have  an  excellent  effect. 

Hypertrophy  foUoiving  Chancroids  of  the  Female   Genital  Organs 

Hypertrophy,  especially  of  the  labia  majora,  is  frequently  seen  in  Avomen 
who  have  been  the  subjects  of  venereal  ulcerations,  and  is  regarded  by 
Gosselin  (^Arch.  gm.  de  med.,  Dec.  1854,  p.  684)  as  so  exclusively  the 
etfect  of  chancroids,  that  its  presence  is  sufficient  to  justify  the  conclusion 
that  a  woman  has  been  thus  diseased.  We  see  the  same  effect  in  the 
thickening  of  the  prepuce  in  the  male  following  sub-preputial  chancroids, 
to  which  I  have  already  referred. 

Chancroids  of  the  Anus  and  Rectum Chancroids  of  the  anus 

and  rectum  may  occur  in  either  sex  from  unnatural  coitus,  but  are  more 
frequent  in  women  owing  to  the  facility  with  which  these  parts  are  soiled 
with  the  secretion  of  sores  situated  upon  the  vulva.  When  seated  upon 
the  margin  of  the  anus,  they  may  readily  be  mistaken  for  fissures.  They 
are  best  exposed  in  women  by  passing  a  finger  into  the  vagina  and  pressing 
the  vagino-rectal  fold  out  through  the  anus.  They  are  attended  by  much 
pain,  especially  during  the  passage  of  the  feces,  which  should  always  be 
rendered  liquid  before  going  to  stool  by  a  mucilaginous  injection.  It  is 
sometimes  advisable  after  clearing  out  the  bowels,  to  thoroughly  cauterize 
the  sore,  and  to  confine  the  patient  to  bed  and  a  low  diet,  and  administer 
opiates  for  the  purpose  of  preventing  any  further  stools  until  cicatrization 
has  taken  place. 

M.  Tardieu*  calls  attention  to  the  fact  that  in  cases  of  the  communication 
of  chancroids  (and  the  same  is  true  of  chancres)  in  unnatural  intercourse, 
the  ulcer  is  usually  found  upon  the  same  side  in  both  of  the  guilty  parties 
— upon  the  right  or  left  side  of  the  penis  in  the  one,  and  upon  the  corre- 
sponding side  of  the  rectum  in  the  other.  This,  of  course,  is  the  reverse 
of  what  holds  good  in  natural  coitus,  in  which  a  sore  upon  one  side  of  the 
penis  or  vulva  is  most  apt  to  be  inoculated  upon  the  opposite  side  of  the 
other  sex. 

Chancroids  of  the  folds  of  the  anus,  even  when  cured — as  virulent  ulcers 
— may  term-nate  in  fissures,  which  are  still  difficult  to  heal,  in  consequence 
of  the  fre(iuent  passage  of  the  feces,  and  the  spasmodic  contraction  of  the 

'  Etude  niedicu-l(;galo  sur  Ics  attontats  aux  mocurs,  1867,  p.  200. 


382  CHANCROID. 

sphincter  ani.  In  sucli  cases  the  only  certain  means  of  relief  is  to  be 
found  in  the  well-known  forcible  dilatation  or  rupture  of  the  sphincter, 
employed  in  ordinary  cases  of  fissure  of  the  anus.     ,  . 

Rollet  advises  repeated  cauterization  of  the  fissure  with  nitrate  of  silver, 
and  a  dressing  of  the  following  ointment : — 

I^.     Glycerine  |j        38 

Aniyli  §ss 15 

Zinci  Oxidi  3ij 8 

This  treatment  may  possibly  succeed  in  mild  cases. 

Chancroids  of  the  anus  and  rectum  not  unfrequently  escape  observation 
from  the  natural  reluctance  of  patients,  especially  women,  to  have  this 
part  of  the  body  examined  ;  and,  indeed,  the  surgeon  himself  is  often  con- 
tent with  an  inspection  of  the  external  orifice  of  the  alimentary  canal, 
when  a  digital  examination  would  reveal  the  presence  of  a  chancroid  in 
the  rectum.  Chancroids  in  this  situation  often  take  on  phagedenic  action 
and  open  a  communication  with  the  vagina.^ 

•  Des  chancres  jihaged^niques  du  rectum,  par  le  Dr.  A.  Despres,  Arcli.  g6ii.  de 
rued.,  mars,  1868. 


INFLAMMATORY    OR    GANGRENOUS    CHANCROID.  383 


CHAPTER    III. 

THE      CHANCROID      COMPLICATED      WITH      EXCES- 
SIVE INFLAMMATION  AND  WITH  PHAGED.ENA. 

Excessive  inflammation  terminating  in  gangrene  gives  rise  to  the 
inflammatory  or  gangrenous  chancroid;  and  phagedenic  ulceration,  in 
several  different  forms,  to  as  many  varieties  of  the  phagedenic  chancroid. 

Inflammatoiiy  OR  Gangrenous  Chancroid.  —  The  inflammation 
attendant  upon  a  chancroid  is  sometimes  so  excessive  as  to  terminate  in 
gangrene,  and  produce  a  slough  of  the  surrounding  tissues,  like  that  caused 
by  the  application  of  a  powerful  caustic.  Age  is  said  to  be  a  predisposing 
cause,  as  is  undoubtedly  a  constitution  originally  defective,  or  one  debili- 
tated by  excess  of  any  kind,  and  especially  by  the  habitual  use  of  alcoholic 
stimulants.  Among  exciting  causes,  are  to  be  mentioned  mechanical  con- 
striction, violence,  indulgence  in  coitus,  excessive  exercise,  want  of  clean- 
liness, and  retention  of  the  secretion  upon  the  surface  of  the  sore,  the  use 
of  improper  dressings,  as  fatty  substances,  and  especially  mercurial  oint- 
ment. The  supervention  of  some  acute  disease  may  also  produce  it.  M. 
Sperino  found  this  complication  occur  in  many  of  the  chancroids  which  he 
inoculated  upon  persons  who  were  afterwards  attacked  with  fever,  and 
particularly  with  intermittent  fever,  which  was  very  common  in  the  neigh- 
borhood of  his  hospital,  at  Turin,  situated  in  a  marshy  district. 

But  this  complication  is  most  frequently  met  with  in  cases  of  congenital 
or  accidental  phimosis,  in  which  the  sore  is  imprisoned  beneath  the  prepuce. 
Tlie  inflammation  progresses  rapidly  and  soon  terminates  in  gangrene. 
The  slough  may  be  limited  to  the  tissues  surrounding  the  ulcer,  and  in- 
volve only  the  internal  layer  of  the  prepuce;  in  which  case  the  chief 
evidence  of  the  occurrence  of  the  complication  is  found  in  the  ichorous 
appearance  and  fetid  odor  of  the  discharge  from  the  preputial  orifice,  and 
the  ultimate  effect  may  be  to  produce  adhesions  of  greater  or  less  extent 
between  the  glans  and  its  envelope. 

In  other  cases,  both  layers  of  tiie  prepuce  are  involved.  The  extremity 
of  the  i)enis  becomes  swollen  and  (jcdematous,  resembling  a  club  or  the 
clapper  of  a  bell ;  a  dark  violet-colored  spot  appears,  either  with  or  with- 
out phlyctenulaj  upon  its  surface,  generally  upon  the  dorsal  aspect,  and 
involves  more  or  less  of  the  prepuce.  If  the  arteria  dorsalis  penis  be- 
come corroded,  dangerous  hemorrhage  may  ensue,  which,  as  shown  by 
experience,  is  not  always  arrested  by  ligatun;  of  the  artery.  If  the  slough 
is  limited  in  extent,  the  glans  penis  often  protrudes  through  the  opening 


384  COMPLICATED    CHANCROID. 

formed,  while  the  preputial  orifice  remains  intact,  and  the  virile  organ 
has  the  appearance  of  being  bifurcated  at  the  extremity.  In  other  in- 
stances the  whole  of  the  prepuce  comes  away,  but  the  progress  of  the 
gangrene  is  usually  limited  at  the  furrow  at  the  base  of  the  glans,  and  the 
patient  is  circumcised  as  accurately  as  if  by  the  surgeon's  knife. 

Paraphimosis  complicating  chancroids  may  i-esult  in  a  similar  manner, 
and  produce  a  slough  of  the  whole  or  a  part  of  that  portion  of  the  prepuce 
(its  mucous  layer)  lying  in  front  of  the  constricting  ring,  together  with 
more  or  less  of  the  glans. 

After  the  fall  of  the  slough,  there  remains  only  a  simple  wound  destitute 
of  virulent  properties. 

It  is  evident  that  excessive  inflammation,  which  is  due  to  simple  causes, 
is  a  mere  complication  of  the  chancroid,  and  does  not  in  itself  change  its 
nature ;  but  its  effect,  when  it  terminates  in  gangrene,  is  exactly  the  same 
as  that  produced  by  the  application  of  a  strong  caustic,  viz.,  the  tissues 
surrounding  the  ulcer  are  involved  in  the  slough  to  an  extent  exceeding 
the  sphere  of  the  specific  influence  of  the  virus.  Consequently,  the  re- 
maining wound  presents  all  the  characteristic's  of  any  simple  sore,  and  its 
secretion  is  not  inoculable. 

Inflammatory  or  gangrenous  chancroids  are  included  by  most  English 
■writers  among  the  phagedenic,  but  there  would  appear  to  be  sufficient  rea- 
son to  follow  the  classification  adopted  by  the  French,  and  consider  them 
as  distinct.     Buboes  are  rare  in  connection  with  this  variety. 

Inflammatory  chancroids  are  to  be  treated  by  confining  the  patient  to 
bed,  low  diet,  mild  purgatives,  leeches  to  the  groin  or  perinseum — never 
on  the  penis  itself — the  local  application  of  cold  or  evaporating  lotions,  or, 
at  a  later  stage,  of  warm  poultices,  as  of  chamomile  flowers,  recommended 
by  Dr.  Hammond  as  the  best  (op.  cit.  p.  SG)  and  other  antiphlogistic 
measures,  so  long  as  the  acute  symptoms  continue  ;  but  if  gangrene  super- 
vene tonics  and  stimulants  are  in  most  cases  required.  If  the  case  be 
complicated  with  phimosis  and  the  ulcer  be  concealed  beneath  the  prepuce, 
the  prepuce  should  at  least  be  slit  up  by  means  of  a  bistoury  carried  along 
a  director  introduced  from  the  orifice,  care  being  taken  to  extend  the  in- 
cision to  tlie  furrow  at  the  base  of  the  glans.  I  think  it  desirable,  how- 
ever, to  avoid,  if  possible,  these  incomplete  operations,  which  leave  the 
penis  in  a  condition  of  deformity,  and  I  therefore  resort  to  complete  cir- 
cumcision in  many  cases,  and  especially  when  the  foreskin  is  unnaturally 
long.  If  the  slough  of  the  tissues  surrounding  the  ulcer  has  already 
formed,  there  is  no  danger  of  inoculation  of  the  edges  of  the  wound ;  and 
even  if  the  gangrene  is  only  commencing  and  the  wound  should  become 
inoculated,  the  fresh  ulceration  will  commonly  heal  as  rapidly  as  the  sub- 
preputial  chancroids,  and  the  patient  will  be  left  in  a  much  better  condi- 
tion than  when  only  a  partial  operation  has  been  performed.  Fuller 
directions  may  be  found  in  the  chapter  on  phimosis. 

Mr.  William  Lawrence,  whose  experience  has  been  very  extensive,  has 
the  following  remaiks  upon  the  indications  for  an  operation  :  "  To  deter- 
mine whether  the  prepuce  should  be  divided  or  not  is  sometimes  a  difl[i- 


PHAGEDENIC    CHANCROIDS.  385 

cult  matter  of  diagnosis.  The  degree  of  redness,  swelling,  and  pain  will 
not  enable  us  to  decide.  The  propriety  of  the  measure  depends  on  the 
condition  of  the  sore  which  we  cannot  see.  The  discharge  from  the  ori- 
fice of  the  prepuce  must  assist  our  judgment  in  doubtful  cases.  An  ichor- 
ous or  sanious  state  of  discharge,  with  fetor,  indicates  sloughing ;  and  in 
such  circumstances  the  division  ought  to  be  performed.  If  the  discharge 
should  be  purulent,  even  though  somewhat  bloody,  and  the  glans  tender 
on  pressure,  we  may  be  contented  with  leeches,  tepid  syringing,  and  mild 
aperients.'" 

If  gangrene  shows  no  tendency  to  self-limitation,  destructive  cauteriza- 
tion should  at  once  be  employed. 

Phagedenic  Chancroids. — In  the  chancroid,  as  commonly  observed, 
the  process  of  ulceration  is  generally  slow  and  limited  in  extent,  and  ad- 
vances with  nearly  equal  rapidity  in  all  directions  ;  whence  the  sore  main- 
tains a  rounded  form,  and  does  not  involve  the  tissues  to  any  great  extent 
or  depth.  Phagedenic  chancroids,  on  the  contrary,  are  characterized  by 
their  more  rapid,  extensive,  and  irregular  progress ;  though  these  charac- 
ters vary  greatly  in  degree  in  different  cases. 

The  following  remarks  are  intended  to  apply  to  phagediena,  not  only 
when  it  attacks  the  original  ulcer,  but  also  when  it  affects  a  virulent  bubo 
or  virulent  lymphitis,  which  are  in  reality  chancroids  of  the  gUmds  or  of 
the  lymphatics. 

These  remarks,  so  far  as  the  symptoms  are  concerned,  are  also  applica- 
ble to  cases  of  phagedicna  attacking  the  initial  lesion  of  syphilis,  in  whicli 
the  indurated  base  of  the  sore  is  commonly  destroyed.  But,  it  sliould  be 
noticed,  a  true  chancre  is  less  frequently  affected  with  phagedtena.  In  mo.-t 
such  instances  that  I  have  seen,  the  induration  remaining  after  the  healino- 
of  the  original  sore  has  itself  become  ulcerated  and  taken  on  phagedenic 
action. 

Induration  of  the  ganglia,  in  the  rare  instances  in  which  it  terminates 
in  suppuration,  is  never  followed  by  phagedasna.  Phagedcena  attacks  a 
bubo  only  when  the  latter  is  virulent  and  due  to  a  chancroid. 

In  the  mildest  and  most  fretjuent  form  of  phagedtena,  the  sore  merely 
extends  in  surface  and  in  de|)tli  sliglitly  beyond  its  ordinary  bounds  ;  this 
is  sometimes  observed  at  all  parts  of  tlie  circumference,  but  generally  at 
one  part  more  than  another,  so  that  the  circular  form  is  lost  and  the  out- 
line becomes  irregular,  but  yet  the  ulcerative  action  is  not  excessive. 

SerpifjinoHS  Chancroid Piiageda^iia  may  stop  here,  or  it  may  go  on  to 

form  a  serpiginous  chancroid  which  is  slow  in  its  progress,  but  to  the  extent 
and  duration  of  which  there  is  no  limit.  The  edges  of  the  sore  in  this 
variety  are  thin,  livid,  and  cedematous.  and  so  extensively  undermined 
that  they  fall  upon  the  ulcerated  surface  or  may  be  turned  back  like  a  flap 
upon  the  souud  skin  ;  they  are  often  perforated  at  various  points,  and  are 
very  irregular  in  their  outline,  resembling  a  festoon.     The  surface  of  tiie 

'  Lecturt'S  on  Surgerv,  London,  18(J3,  p.  390. 
25 


386  COMPLICATED    CHANCROID. 

sore  is  uneven,  and  covei'ed  with  a  thick  pultaceous  and  grayish  secretion, 
through  whicli  florid  granulations  at  times  protrude  and  bleed  copiously 
upon  the  slightest  touch.  Serpiginous  chancroids  are  not  attended  by 
much  constitutional  reaction.  They  exhibit  a  predilection  for  the  super- 
ficial cellular  tissue,  and  are  inclined  to  extend  in  surface  rather  than  in 
depth.  They  sometimes  undermine  tlie  whole  skin  of  the  penis  as  far  as 
the  pubes,  or  make  their  way  down  the  thigh  nearly  to  the  knee,  or  up- 
wards upon  the  abdomen,  or  follow  the  course  of  the  crest  of  the  ilium. 
They  often  advance  on  one  side  while  they  are  healing  upon  the  opposite. 
Their  progress  may  appear  to  be  arrested  and  the  sore  nearly  cicatrized, 
when  rapid  ulceration  again  sets  in  and  destroys  the  newly-formed  tissue. 
Their  secretion  is  copious,  thin,  and  sanious,  and  preserves  its  contagious 
properties  through  the  many  years  that  the  ulcer  may  persist.  They  leave 
behind  them  a  whitish  and  indelible  cicatrix,  resembling  that  produced  by 
a  deep  burn. 

This  sore  may  be  mistaken  for  the  serpiginous  ulceration  of  tertiary 
syphilis.  It  is  distinguished  from  it  by  the  fact  that  it  commences  with 
a  chancroid — usually  sfeated  upon  the  genitals — or  with  a  suppurating 
bubo  in  the  groin  ;  that  from  this  point  of  origin  it  extends  by  a  continu- 
ous process  of  ulceration,  the  course  of  which  is  evident  from  the  foul 
cicatrix  which  it  leaves  behind;  and  that  it  never  overleaps  sound  por- 
tions of  the  integument.  Moreover,  the  fluidity  of  its  secretion  does  not 
favor  the  formation  of  scabs,  and  its  contagious  properties  are  manifest  if 
inoculated  upon  the  person  bearing  it.^ 

Sloughing  PJiagedenic  Chancroid A  third  variety  is  called  the  slough- 
ing phagedenic  ulcer,  and  is  characterized  by  the  greater  acuteness,  rapidity, 
and  depth  of  the  destructive  action.  Its  symptoms  closely  resemble  those 
of  hospital  gangrene.  There  is  considerable  constitutional  disturbance,  a 
full  and  hard  pulse,  furred  tongue,  and  other  symptoms  of  fever.-  The 
pain  is  often  excessive,  and  almost  insupportable.  The  ulcer  extends 
chiefly  to  dependent  parts  in  the  neighborhood,  which  are  infiltrated  by 
its  copious  and  foul  secretion.  It  respects  no  tissue  whatever,  and  its 
ravages  are  sometimes  terrible ;  the  glans,  penis,  or  labia  may  be  wholly 
destroyed,  and  the  testicles  entirely  laid  bare.  Fatal  hemorrhage  has 
been  known  to  occur  from  ulceration  of  the  arteria  dorsalis  penis. 
The  sloughing  phagedenic  chancroid  is  most  common  among  the  intempe- 
rate and  lowest  class  of  prostitutes,  and  also  among  persons  visiting  hot 
climates  or  exposed  to  various  hardships.  It  was  this  variety  which  deci- 
mated the  English  troops  in  the  Peninsular  war,  although  venereal  dis- 
eases were  at  the  time  comparatively  mild  among  the  natives. 

Phagedenic  chancroids  are  not  unfrequently  attended  by  buboes,  which 
generally  take  on  the  same  destructive  action  as  themselves. 

Fournier's  confrontations,  already  referred  to,  prove  that  the  phage- 
denic chancroid  is  not  always  transmitted  in  its  kind,  and  that  hence  it 
cannot  dei)end  upon  a  distinct  poison.     This  does   not,  however,  conflict 

'  Bassereau,  op.  cit.  p.  475. 


TREATMENT    OF    PHAGEDENIC    CHANCROID.  887 

v,'itli  the  fact  that  contagious  matter  possesses  noxious  properties  propor- 
tionate to  the  degree  of  its  putrescence,  when  such  has  taken  place.  ^V'e 
have  an  instance  of  this  in  the  disastrous  effects  of  wounds  acquired  in 
the  dead-house.  Witness  also  the  mortality  in  the  town  of  Westford, 
Mass.,  in  the  spring  of  18G0,  following  vaccination  with  scabs  originally 
pure,  but  which  were  dissolved  in  water  and  exposed  to  air  and  heat 
until  they  were  decomposed.'  In  most  cases,  however,  phagedaina  is 
doubtless  dependent  upon  some  form  of  constitutional  cachexia,  the  exact 
nature  of  which  is  not  always  apparent.  The  abuse  of  mercury  in  the 
treatment  of  venereal  ulcers  is  another  cause,  which  was  more  frequent  a 
few  years  since  than  now,  and  the  improved  practice  of  the  present  day 
may  account  in  a  measure  for  the  partial  disappearance  of  this  variety. 

Treatment  of  Phagedcena The  general  treatment  of  phagedenic  ulcers 

should  be  based  upon  a  knowledge  of  the  cause  of  the  destructive  action 
when  this  can  be  ascertained.  Phagedena  most  frequently  occurs  in 
persons  debilitated  by  various  causes,  as  intemperance,  irregularity  of  life, 
want,  or  a  residence  in  damp,  unhealthy  apartments ;  in  these  cases, 
nourishing  food,  the  ordinary  comforts  of  life,  and  the  mineral  or  vegetable 
tonics  are  required.  Scrofula  is  another  fruitful  source  of  phagedtena,  and 
calls  for  preparations  of  iodine  and  other  antistrumous  remedies.  Moderate 
doses  of  opium  repeated  at  short  intervals,  so  as  to  keep  the  patient  gently 
under  its  influence,  are  often  of  essential  service  in  allaying  pain,  and  in 
controlling  the  progress  of  the  disease.  Numerous  observers  have  called 
attention  to  the  beneficial  effect  of  this  agent  upon  ulcerative  action,  and 
have  ascribed  to  it  a  decidedly  tonic  influence.  Rodet  reports  several 
cases  of  serpiginous  chancroids  which  resisted  a  great  variety  of  means,  but 
which  yielded  to  opium.  This  surgeon  commences  with  about  one  o-rain 
of  the  extract  of  opium  morning  and  night,  and  gradually  but  rapidly  in- 
creases the  dose  so  that  the  system  mny  not  become  habituated  to  it  before 
its  therapeutic  effect  takes  place.  He  prefers  two  large  doses  in  the 
twenty-four  hours  to  smaller  ones  more  frequently  repeated,  in  order  that 
digestion  may  go  on  unimpeded  in  the  intervals.  Light  wines  ai'e  largely 
administered  at  the  same  time,  and  are  said  to  correct  any  tendency  to 
constipation. 

In  many  cases  it  is  impossible  to  discover  the  cause  of  phagedasna.  The 
general  condition  of  the  patient  is  good;  all  his  functions  are  duly  per- 
formed ;  and  yet  his  ulcer  continues  to  extend.  In  such  cases  our  chief 
reliance  must  be  placed  u{)on  local  applications  and  deep  cauterization,  and 
the  general  treatment  must  be  experimental. 

Ricord  placed  great  reliance  on  the  potassio-tartrate  of  iron,  which  he 
called  the  "  born  enemy  of  phagedfcna."  He  administered  it  internally  in 
doses  of  two  teaspoonfuls  to  a  tablespoonful  of  the  following  mixture  three 
times  a  day  after  meals,  also  applying  a  lotion  of  the  same  salt  to  the 
ulcer : —         * 

'  Boston  M.  and  S.  J.,  May,  1860. 


388  COMPLICATED    CHANCROID. 

I^.     Ferri  et  Potassse  Tartratis,  §ss      ...  151 

Aquse,  ^iij •     .     .     .  90| 

Syrupi,  gUj 1101 

M. 

Ricord's  praise  of  this  remedy  has  not  been  confirmed  by  my  own,  more 
matnre  experience,  or  that  of  others. 

Great  benefit  is  to  be  derived  from  the  local  application  of  iodoform, 
as  recommended  in  the  treatment  of  the  chancroid.  Under  its  influence 
the  pain  is  allayed  and  the  ulcer  will  frequently,  without  other  measures, 
take  on  healthy  action.  The  iodoform  may  be  applied  in  powder  or  ethe- 
rial  solution  once  a  day,  and  the  sore  be  dressed  with  an  ointment  contain- 
ing a  drachm  of  iodoform  to  the  ounce  of  lard  or  vaseline. 

Probably  no  treatment  affords  better  results  in  obstinate  cases  of  phage- 
denic ulcerations  than  the  prolonged  immersion  of  the  parts  in  hot  water, 
a  method  employed  by  Ilebra  in  various  affections  of  the  skin.  If  the 
ulceration  be  confined  to  the  genitals,  an  ordinary  sitz-bath  will  answer  the 
purpose ;  if  more  extensive,  a  full  bath  will  be  required.  In  the  former 
case,  a  large  sponge  is  convenient  for  the  patient  to  sit  upon.  Immersion 
for  eight  or  ten  hours  a  day,  care  being  taken  to  keep  the  parts  affected 
below  the  surface  of  the  water,  is  desirable  ;  as  the  case  improves,  immer- 
sion every  other  hour  may  suffice.  The  water  should  be  kept  at  a  tem- 
perature of  about  98°,  and  the  upper  part  of  the  body  be  protected  by 
suitable  covering.  At  night,  a  dressing  of  iodoform  should  be  applied, 
and  the  same  be  allowed  to  soak  in  the  bath  the  next  morning  before 
removal.  By  this  treatment,  the  sufferings  of  the  patient  are  not  only 
greatly  relieved,  but  the  effect  in  arresting  the  progress  of  the  ulceration 
and  inducing  reparative  action  is,  in  most  cases,  astonishing.^ 

Weisflog-  uses  a  Faradic  bath,  one  electrode  being  connected  with  the 
bottom  of  the  tub.  The  patient,  when  immersed,  touches  the  other  elec- 
trode, covered  with  a  moistened  sponge,  with  one  or  more  fingers,  according 
to  the  sensations  produced  in  the  ulcer. 

Our  last  resort  for  the  cure  of  phagedenic  chancroids  is  the  complete 
destruction  of  the  sore  by  a  powerful  caustic  or  the  actual  cautery.  In 
cases  of  a  comparatively  mild  character,  we  may  rely  upon  the  application 
of  fuming  nitric  acid,  taking  care  to  apply  it  to  every  crevice,  especially 
beneath  the  edges  of  the  undermined  integument.  If  the  smallest  loophole 
be  left  from  which  virulent  pus  can  proceed,  it  will  inoculate  the  wound 
remaining  after  the  fall  of  the  eschar,  and  the  only  effect  of  the  treatment 
will  be  to  increase  the  size  of  the  ulcer.  It  is  evident,  therefore,  that 
cauterization,  in  order  to  be  a  benefit  and  not  an  injury,  must  be  thorough 
and  complete.  In  severe  cases  Ricord  repeats  the  application  as  often  as 
twice  a  day,  and  in  the  mean  while  dresses  the  sore  with  lint  soaked  in 

•  See  articles  by — Dr.  Simmons,  of  Yokoliama,  Med.  Rec,  N.  Y.,  Sept.  11,  1875. 
R.  W.  Taylor,  Review  in  Arch,  of  Dermat.,  N.  ¥.,  vol.  ii,  1876,  p.  183. 
Arthur  Cooper,  Lancet,  bond.,  May  24,  1879,  p.  731. 

2  Arch.  f.  path,  anat.,  etc.  (Virchow),  Berl.,  B.  (jC,  s.  311,  and  Practitioner, 
Lond.,  March,  1879,  p.  216. 


TREATMENT    OF    PHAGEDENIC    CHANCROID.  389 

aromatic  wine  or  a  solution  of  the  potassio-tartrate  of  iron.  Pain  and 
swelling  are  not  always  contra-indications  to  the  use  of  the  caustic,-  which 
is  frequently  the  most  effective  sedative  that  can  be  employed. 

The  carbo-sulpliuric  paste  (see  p.  367)  is  also  an  excellent  caustic,  and 
does  its  work  better  than  any  other,  with  the  exception  of  the  actual 
cautery. 

Other  caustics  recommended  by  authors  are — 

Pure  hromine. 

The  permanganate  of  potassa,^  of  which  a  saturated  solution  (gr.  85 
to  water  ^j)  may  be  applied  three  or  four  times  a  day,  and  the  sores 
dressed  meanwiiile  with  lint  soaked  in  a  mixture  of  a  di-achm  of  the  satu- 
rated solution  to  the  pint  of  water. 

Carbolic  acid  has  been  more  recently  employed  for  the  same  purpose, 
and  is,  I  believe,  still  more  efficacious.  The  surface  of  the  sore  may  be 
painted  over  with  the  impure  liquid  acid,  and  afterwards  dressed  with  a 
solution  of  the  same,  of  the  strength  of  two  drachms  to  the  pint  of  water. 

T/ie  actual  cautery  may  still  be  required  in  the  more  severe  cases  of 
phagedaina,  when  other  means  have  failed;  and  the  extent  of  tlie  surface 
involved  by  the  ulceration  should  be  no  bar  to  its  free  application.  P^ither 
the  old  cauterizing  irons,  or,  better  still,  Paquelin's  thermo-cautery  or  the 
galvano-cautery,  is  best  adapted.  A  "white  heat"  is  required,  and  the 
patient  should  be  rendered  insensible  by  an  anaesthetic. 

The  ulcer  should  first  be  cleansed  by  washing  it  copiously  with  water, 
removing  all  adherent  matter,  and  then  drying  it.  Every  portion  of  the 
secreting  surface  should  now  be  deeply  cauterized,  carrying  the  hot  iron 
into  every  nook  and  sinus,  and  paying  special  attention  to  the  parts  over- 
lapped by  the  skin  of  the  edges.  These  flaps  of  integument  should  be 
cauterized  not  only  upon  the  under,  but  also  upon  the  outer  surface,  so  as 
to  be  for  the  most  part  destroyed.  A  cold  water-dressing  is  afterwards 
applied,  and  the  patient,  on  waking,  does  not  suffer  much  more  than  he 
did  before  the  operation.  When  suppuration  commences,  Goulard's  ex- 
tract or  aromatic  wine  may  be  added  to  the  lotion. 

An  attack  of  erysipelas  has  been  known  to  arrest  the  progress  of  phage- 
dsena  and  to  induce  cicatrization  of  serpiginous  ulcers  which  have  proved 
intractable  under  almost  every  form  of  medication.  An  instance  of  this 
kind  is  contributed  by  M.  liuzenet  to  Ricord's  Lcr^oas  siir  la  chancre,  and 
several  are  re{)orted  by  other  surgeons. 

Attempts  to  cure  serpiginous  cliaiicroids  by  means  of  "  syphilization" 
have  signally  failed. 

'  Soo  "Remarks  on  the  Use  of  Permanganate  of  Potassa,"  by  Dr.  F.  Iliiikle, 
Am.  M.  Times,  N.  Y.,  Nov.  28,  1863. 


390  CHANCROID    COMPLICATED    "WITH    SYPHILIS. 


CHAPTER    IV. 

THE   CHANCROID   COMPLICATED   WITH    SYPHILIS. 
—  "MIXED   CHANCRE." 

Syphilitic  infection  of  the  system  presents  no  barrier  to  the  existence 
of  a  cliancroid,  and  vice  versa.  Universal  experience  confirms  the  state- 
ment that  a  person  presenting  sypliilitic  symptoms,  whether  primary, 
secondary,  or  tertiary,  may  contract  a  chancroid,  which  will  run  the  same 
course  as  in  a  person  free  from  syphilis.  Moreover  two  inoculations,  one 
with  the.  chancroidal  and  the  other  with  the  syphilitic  virus,  may  occur 
side  by  side,  and  the  resultant  chancroid  and  chancre  will  each  pursue  its 
normal  course  uninfluenced  by  the  neighborhood  of  the  other;  and,  finally, 
two  such  inoculations  may  take  place  at  one  and  the  same  point  and  pro- 
duce a  sore  possessing  all  the  properties  of  the  chancroid  and  the  primary 
syphilitic  ulcer,  viz.,  on  the  one  hand,  ready  auto-inoculability  and  the 
power  of  producing  a  suppurating  bubo  secreting  inoculable  pus;  and  on 
the  other,  an  indurated  base,  induration  of  the  neighboring  ganglia,  and  a 
secretion  capable  of  communicating  syphilis  to  a  person  free  from  previous 
syphilitic  taint. 

I  have  denominated  such  a  sore  a  "chancroid  complicated  with  syphilis." 
It  would  clearly  be  just  as  appropriate  to  call  it  "primary  syphilis  com- 
plicated with  the  chancroid."  The  French  have  named  it  the  "mixed 
chanci-e,"  and  it  has  been  the  subject  of  much  discussion,  as  noticed  in 
the  Introduction  to  the  present  work,  in  connection  with  the  doctrines  of 
the  Lyons  school.     It  is  hardly  deserving  of  a  distinct  name,  since 

A  '■'■mixed  chancre"  is  nothing  more  nor  less  than  a  sore  resulting  from 
the  inoculation,  at  the  same  spot,  of  the  syphilitic  virus  and  of  the  chan- 
croid(d  poison,  the  product  of  simple  inflammation.  The  implantation 
of  the  two  kinds  of  virus  may  take  place  synchronously,  as,  for  instance, 
in  the  same  act  of  coitus  when  a  man  has  connection  with  a  woman  affected 
with  a  cliancroid  and  also  with  syphilitic  manifestations;  or  the  inoculation 
of  either  virus  may  occur  upon  a  previously  existing  ulcer  of  the  opposite 
species.  In  either  case,  when  fully  developed,  the  mixed  chancre  may  be 
perpetuated  in  its  kinds  by  successive  inoculation  from  one  individual  to 
another. 

Prior  to  its  full  development — supposing  the  inoculations  of  the  two 
kinds  of  virus  to  have  taken  place  at  the  same  time — the  chancroid,  having 
no  period  of  incubation,  will  first  appear,  and  can  only  by  contagion  give 
rise  to  a  chancroid;  while,  again,  towards  the  close  of  the  ulceration, 
wliichever  virus  persists  in  the  sore  the  longer  will  ultimately  transmit 
itself  alone  in  its  species. 


CASES.  391 

The  following  instance  in  which  a  mixed  chancre  was  developed  by  tlie 
inoculation  of  a  primary  syphilitic  ulcer  with  the  chancroidal  poison,  is 
reported  by  Fournier  : — 

Alphonse  N.,  aged  17,  contracted  a  chancre  in  the  latter  part  of  Sept. 
1857.  He  became  an  out-patient  of  the  Hopital  du  Midi,  Oct.  3,  when  a 
chancre,  surrounded  with  cartilaginous  induration,  was  found  in  the  fossa 
behind  the  corona  glandis,  and  the  glands  in  both  groins  were  enlarged, 
hard,  and  indolent.  A  dressing  with  aromatic  wine  was  ordered  for  the 
sore,  and  mercury  internally. 

Oct.  14.  The  chancre  has  entered  upon  the  period  of  repair  ;  it  is  less 
excavated,  and  its  edges  less  prominent. 

Oct.  24.  There  has  been  a  change  for  the  worse.  The  original  chancre 
has  increased  in  surface  and  in  de|)th;its  base  is  still  very  much  indurated. 
Moreover,  upon  the  skin  of  the  penis  is  found  another  large  ulcer ;  its  base 
oedematous,  but  without  true  induration.  There  are  also  several  small 
ulcers  with  soft  bases  upon  the  external  surface  of  the  prepuce.  Tlie 
patient  declares  most  positively  that  he  has  had  had  no  sexual  connection 
since  he  contracted  his  first  chancre.  Are  the  recent  sores  to  be  attrib- 
uted to  accidental  inoculation  from  the  first  ?  N.  is  this  day  admitted  as 
an  in-patient. 

In  the  early  part  of  Nov.  one  of  the  lymphatic  ganglia  in  the  left  groin 
became  acutely  inflamed,  and  presented  all  the  characters  of  a  bubo  de- 
pendent upon  a  chancroid.  It  suppurated,  and  its  pus  loas  inoculated 
tvith  success.  In  the  right  groin,  the  enlargement  and  induration  of  the 
ganglia  characteristic  of  a  chancre  remained  as  before. 

In  Dec.  secondary  symptoms  appeared ;  roseola  and  multiple  mucous 
patches. 

In  spite  of  the  patient's  denial,  Ricord  attributed  the  more  recent  ulcers 
to  a  second  exposure  and  fresh  contagion ;  and  a  i'ew  days  after  his  entrance 
into  the  hospital,  the  patient  privately  confessed  to  M.  Fournier,  the  In- 
terne, that  on  Oct.  l.oth  he  had  connection  with  a  woman  whose  name  and 
address  he  gave.  He  also  stated  that  on  the  following  day  his  first  ulcer 
began  to  enlarge,  and  the  others  appeared  two  days  after. 

Fournier  immediately  visited  the  woman  indicated  by  N.,  and  found 
that  she  had  three  large  chancroids  with  perfectly  soft  bases,  situated  upon 
the  internal  surface  of  the  left  labium,  on  the  fourchette  and  u])on  tlie  folds 
at  the  entrance  of  the  vagina,  and  of  about  three  weeks'  duration.  The 
inguinal  ganglia  were  in  a  normal  condition. 

This  woman  also  confessed  to  M.  Fournier  that  she  had  infected  her 
lover,  Charles  V.,  who,  by  a  singular  coincidence,  was  at  that  moment  a 
patient  in  the  I16i»ital  du  Midi,  and  who  likewise  had  several  chancroids 
with  soft  bases  upon  the  prepuce  and  an  acute  bubo  in  the  left  groin. 

To  sum  vp  this  history  :  a  man  with  a  primary  syphilitic  ulcer  in  tlie 
period  of  repair  and  an  indolent  indurated  bubo  has  connection  with  a 
woman  affected  with  chancroid.  He  contracts  fresh  ulcers,  which  i)rove 
to  be  chancroids,  and  one  of  which  is  seated  upon  the  surface  of  the  orig- 
inal chancre.     An  inflammatory  bubo  appears,  which  suppurates  and  fur- 


302  CHANCROID    COMPLICATED    WITH    SYPHILIS. 

nishes  inoculable  pus.  Finally,  symptoms  of  general  syphilis  are  devel- 
oped.' 

Rollet  relates  a  similar  case: — 

G.  Francois,  aged  20,  entered  the  Antiquaille  Hospital,  at  Lyons,  with 
a  sore  situated  upon  the  meatus,  which  was  slightly  indurated  and  pre- 
sented the  usual  aspect  of  a  chancre.  The  fossa  at  the  base  of  the  glans 
was  also  studded  with  several  ulcers  which  were  as  soft  as  possible.  The 
ganglia  in  the  groin  were  indurated.  In  six  weeks  after  exposure,  the 
patient  was  attacked  with  headache,  syphilitic  roseola,  and  rheumatic 
pains. 

In  order  to  confirm  the  diagnosis  as  to  the  nature  of  the  sores,  Rollet 
inoculated  matter  from  the  one  which  was  indurated  upon  the  left  thigh, 
and  the  secretion  of  the  others  upon  the  right.  The  result  was  positive  in 
both.  It  was  then  thought  that  pus  from  the  simple  sores  might  have 
been  deposited  upon  the  indurated  one,  and  thence  taken  up  upon  the 
lancet.  Rollet  therefore  waited  until  the  chancroids  in  the  fossa  behind 
the  corona  had  completely  Iiealed,  and  then,  after  repeatedly  cauterizing 
the  indurated  sore  with  solid  nitrate  of  silver,  inoculated  its  secretion  a 
second  time.  This  inoculation  produced  the  characteristic  pustule  of  a 
chancroid  as  before  ;  thei'eby  showing  that  the  success  of  the  first  inocula- 
tion was  not  owing  to  the  presence  of  matter  which  had  been  simply  de- 
posited and  again  taken  up,  but  to  the  inherent  properties  in  the  secretion 
of  the  sore  itself.'' 

M.  Rollet  and  his  Interne,  M.  Laroyenne,  were  led  by  this  case  to  try 
the  effect  of  inoculating  cliancres  with  matter  from  a  chancroid.  Their 
experiments  are  briefly  related  as  follows: — 

Case  1.  Fieri  M.  ;  indurated  chancre  of  the  meatus;  duration  three 
weeks;  indurated  ganglia;  inoculation  of  the  secretion  of  the  chancre, 
negative.  Sept.  14,  the  pus  of  a  chancroid  was  deposited  upon  t\ve  sore. 
8e[)t.  15,  a[)plication  of  the  solid  nitrate  of  silver;  lotions;  dressing  with 
aromatic  wine.     Sept.  19,  second  inoculation  ;  chancroidal  pustule. 

Case  2.  John  L. ;  indurated  ulcer  almost  healed;  indurated  ganglia: 
general  treatment  and  local  application  of  aromatic  wine  ;  inoculation  neg- 
ative. Nov.  18,  pus  from  a  chancroid  is  applied  to  the  ulcer  ;  treatment 
continued.      Nov.  23,  second  inoculation  ;  this  time  positive. 

Case  3.  Robert  M.  ;  parchment  variety  of  chancre  upon  the  skin  of  the 
penis;  duration  five  days.  Dec.  11,  inoculation  without  result;  dress  with 
opiated  cerate  and  calomel.  Dec.  16,  application  of  the  virus  of  a  chan- 
croid.    Dec.  17,  same  dressing.      Dec.  22,  inoculation  positive. 

Case  4.  Peter  M.  ;  chancre  of  six  weeks'  duration,  occupying  three- 
fourtiis  of  the  circumference  of  the  fossa  glaudis.  Dec.  11,  inoculation 
unsuccessful.  Dec.  16,  application  of  the  virus  of  a  chancroid.  Dec.  17, 
dress  with  opiated  cerate  with  addition  of  calomel.  Dec.  22,  inoculation 
successful. 

•  LeQons  sur  Ic  chancre,  p.  119. 

2  Lakoyenxe,  Etudes  experimentales  sur  le  chancre,  Annuaire  de  la  syph.  et  d. 
mal.  de  la  peau,  Paris,  Annee  1858,  p.  248. 


CASES.  o93 

According  to  Rollet,  t%A-o  or  three  days  after  the  application  of  the  vims 
of  a  chancroid  to  a  chancre,  the  sore  assumes  a  grayish  aspect  like  an  or- 
dinary chancroid,  hut  is  less  excavated;  its  edges  become  jagged,  and  its 
purulent  secretion  more  copious  and  sanious  ;  it  may  give  rise  to  successive 
chancroids  in  the  neighborhood  or  to  a  virulent  bubo.  It  preserves,  how- 
ever, the  essential  characters  of  a  chancre,  and,  among  others,  induration 
of  its  base,  which  is  always  pathognomonic  ;  the  ganglia  of  both  groins  are 
indurated  as  usual,  unless  a  virulent  bubo  supervenes,  when  those  of  the 
opposite  side  may  still  indicate  the  nature  of  the  disease.  The  general 
symptoms  following  the  chancre  are  not  modified  by  this  inoculation,  and 
secondary  symptoms  appear  at  the  same  time  and  in  the  same  manner  as 
under  ordinary  circumstances.  The  more  copious  secretion  of  the  chan- 
croid renders  this  species  more  liable  to  be  ingrafted  upon  a  chancre  than 
the  latter  upon  the  former. 

Thus  far  we  have  supposed  the  inoculation  of  one  species  of  virus  to 
succeed  that  of  the  other,  but  both  sometimes,  though  rarely,  occur  during 
the  same  act  of  coitus.  In  this  case  the  chancroid,  which  has  no  period 
of  incubation,  is  first  developed  in  its  usual  form,  with  abrupt  edges,  gray- 
ish floor,  and  soft  base  ;  subsequently  the  chancre  appears,  when  the  base 
of  the  sore  and  the  neighboring  lymphatic  ganglia  become  indurated. 

The  union  of  the  two  species  of  virus  in  this  variety  is  analogous  to  the 
mixture  which  takes  place  when  gonorrha3a  is  complicated  with  urethral 
chancre,  constituting  the  only  true  "  gonorrhoea  virulenta  ;"  and  also  to 
the  union  of  either  the  chancroidal  or  syphilitic  virus  with  that  of  vaccinia, 
of  whicii  a  number  of  examples  are  recorded. 

The  mixed  chancre  requires  the  local  treatment  of  the  chancroid  and 
the  general  treatment  of  syphilis. 


394  THE    SIMPLE    AND    THE    VIRULENT    BUBO. 


CHAPTER  V. 

THE    SIMPLE    AND   THE   VIRULENT    BUBO. 

Bubo,  derived  from  the  Greek  j5ov^icv,  originally  signified  either  the 
groin,  the  glands  in  the  groins,  or,  again,  inflammation  of"  these  glands. 
In  more  modern  times,  the  term  has  been  applied  in  general  to  auy  affec- 
tion of  the  lymphatic  ganglia.  Thus  we  read  of  sci'ofulous  buboes  depen- 
. dent  upon  a  strumous  diathesis;  of  cancerous  buboes  dependent  upon  a 
scirrhous  tumor  in  the  neighborhood  ;  and  of  the  Plague  of  the  Levant 
(the  bubo-pest),  characterized,  among  other  symptoms,  by  an  affection  of 
the  lymphatic  glands  of  the  groins  and  axillae.  The  meaning  of  the  word, 
so  far  as  having  any  connection  with  the  groin,  and  so  far  as  dependent 
upon  any  causes  which  can  exclusively  affect  the  groin,  has,  therefore,  been 
departed  from. 

In  common  parlance,  however,  if  we  hear  the  expression  "  that  man 
has  a  bubo,"  we  infer  that  he  has  an  affection  of  one  of  the  lymphatic 
ganglia  dependent  upon  venereal  disease ;  and  venereal  diseases  are,  of 
course,  those  only  which  concern  us  in  the  present  work.  At  the  same 
time,  let  it  be  observed,  so  far  as  the  situation  of  the  tumor  is  concerned, 
that  a  venereal  bubo  is  a  bubo,  no  matter  where  situated  ;  and  that,  even 
if  dependent  directly  or  indirectly  upon  venereal  contagion,  other  causes 
than  venereal  often  play  an  important  part  in  its  evolution. 

We  shall  find  hereafter  that  sypJiilts  exerts  a  peculiar  influence  upen  the 
lymphatic  ganglia  at  two  periods  of  its  course:  1,  In  its  initial  stage,  upon 
the  glands  in  anatomical  relation  with  the  chancre;  2,  In  its  period  of  full 
development,  upon  the  glandular  system  at  large.  With  these,  so-called 
"  indurated"  and  "  constitutional"  buboes,  which  are  inevitable  to  syphilis, 
and  which  will  be  considered  further  on,  we  have  at  present  nothing  di- 
rectly to  do,  although  what  we  have  to  say  of  the  anatomical  connection 
between  the  glands  and  the  lymphatics  will  be  found  to  have  a  bearing  ui)on 
them.  In  speaking  of  buboes  in  this  chapter,  we  refer,  therefore,  only  to 
those  which  are  not  specific  in  their  origin.  They  are  two  in  number: — • 
I.  The  Simple  Bubo. 

II.  The  Virulent  Bubo. 

Frequency  of  Buboes — All  persons  are  not  disposed  alike  to  the  de- 
velopment of  buboes.  In  those  of  a  strumous  constitution,  the  lymphatic 
system  ai)pears  to  be  much  more  sensitive  than  in  others,  and  buboes  are 
of  more  frequent  occurrence.  In  general,  they  are  found  oftener  in  men 
than  in  women,  partly,  doubtless,  in  consequence  of  the  different  habits  of 


SEAT    OF    BUBOES.  395 

life  in  the  two  sexes.  It  has  been  estimated  that  40  out  of  every  100  men 
with  chancroids  are  attacked  with  buboes  ;  and  of  these  40,  that  from  30  to 
35  have  suppurating  buboes  ;  while  of  every  100  women  affected  with  chan- 
croids, only  20  have  acute  inflammation  of  the  ganglia,  of  which  lo  sup- 
purate. Zeissl  ascribes  this  difference  not  only  to  the  more  active  habits  of 
the  male  sex,  but  also  to  the  fact  tliat  the  majority  of  venereal  affections  in 
women  are  situated  upon  the  mucous  membrane  and  not  upon  the  external 
integument,  wliere  their  occurrence  is  found  by  experience  to  be  followed 
most  frequently  by  buboes  in  the  male  sex  also. 

As  to  the  comparative  frequency  of  the  simple  and  virulent  bubo,  sta- 
tistics vary  greatly.  Jullien'  states,  as  the  result  of  the  collected  observa- 
tions of  a  number  of  authorities,  that  of  287  buboes,  149  were  simple 
and  138  virulent.  These  statistics,  however,  must  not  be  regarded  at  all 
as  conclusive,  since  the  diagnosis  between  a  simple  and  a  virulent  bubo 
requires  an  amount  of  care  and  precision  on  the  part  of  the  observer 
which  is  rarely  given. 

Seat  of  Buboes — The  inguinal  ganglia  are  most  frequently  affected 
in  cases  of  buboes,  and  the  anatomical  seat  of  these  ganglia  is  of  no  little 
interest  as  showing  what  course  such  tumors  may  take.  This  subject  has 
been  most  thoroughly  investigated  in  two  admirable  lectures  by  Prof. 
Auspitz,^  of  Vienna,  one  of  whose  plates  (Fig.  114)  we  reproduce,  and 
whose  description  we  shall  closely  follow. 

The  inguinal  ganglia  are  divided  by  anatomists  into  the  superficial  and 
the  deep.  The  former  are  the  more  constant,  indeed  always  present,  and 
of  the  greater  importance.  They  are  seated  in  the  subcutaneous  cellular 
tissue,  separated  from  the  surface  only  by  the  skin  and  a  thin  layer  of  con- 
nective tissue — the  "  superficial  fascia,"  and  lying  upon  the  "  fascia  lata." 
The  richness  of  the  tissue  in  which  they  are  imbedded  depends  greatly 
upon  the  amount  of  corpulency  of  the  individual.  They  vary  to  some 
extent  in  their  number  and  situation  ;  these,  however,  are  so  generally  con- 
stant as  not  to  differ  materially  from  the  accompanying  representation, 
which  includes  the  lymphatic  vessels  merging  into  them. 

Of  these  groups  of  glands,  A  and  B  are  strictly  inguinal,  while  D  is 
strictly  femoral.  The  group  C  belongs  rather  to  the  inguinal  glands,  with 
which  it  stands  in  closer  anatomical  and  pathological  relations  tlian  to  the 
femoral. 

Deep-seated  inguinal  ganglia,  underlying  the  fascia  lata,  described  by 
most  anatomists  as  four  to  six  in  number,  are  far  from  being  constant. 
Auspitz  lias  found  only  one  usually  [)resent,  and  this,  "  Rosenmiiller's 
gland,"  situated  between  the  semilunar  edge  of  Gimbernat's  ligament  and 
the  vena  cruralis. 

In  women,  vessels  from  the  lym[)hatic  network  of  the  labia  majora  and 

'  Trait<i  praliquo  d.  mal.  v6n.,  Paris,  1879,  p.  429. 
2  Arch.  t'.  dcrmat.  u.  sjpli.,  I'rag,  1873,  iii  u.  iv  Heft. 


396 


THE    SIMPLE    AND    THE    VIRULENT    BUBO. 


minora,  connecting  witli  that  of  tlie  vagina,  run  beneath  the  skin  of  the 
hibia  and  terminate  in  ghuuls  situated  in  the  same  manner  as  in  the  male. 
Tiie  anatomical  connection  between  the  above  mentioned  ganglia  and 
the  exact  seat  of  any  lesion  affecting  them,  will  determine  which  of  them 
will  become  exclusively  or  chiefly  involved.  "  If  the  exciting  cause  be 
seated  on  the  prepuce  or  glans  penis,  the  group  B  is  in  the  first  place, 

Ficr.  114. 


Schematic  representation  of  the  Bupr^rflcial  inguinal  ganu'lia  (Auspitz).  ah,  Poupart's  liga- 
ment. ,V,  Vas  defen-ns.  A,  S,,aQ'i  Bo,  C  and  D,  Inguinal  ganglia.  1.  Lymphatic  ve.s)<el  run- 
ning along  the  dorsal  groove  of  the  pi^nis  ;  2  ami  3,  vessels  running  along  its  riglit  side  ;  these 
three  anastomose  in  the  corona  glandis.  1  hecnmes  divided  near  the  root  of  the  penis  into  two 
lateral  liranches,  which,  as  well  as  2  and  3,  terminate  in  the  inguinal  ganglia.  .'5,  vessels  coming 
from  near  the  ant.  sup.  spine  of  the  ilium  to  the  ganglion  A.  6,  ditto  from  the  hypogastiium  to 
the  game  ganglion.    4,  ditto  from  the  lower  extremity  to  the  gland  D. 


in  tlic  next  place  C  and  A,  and  only  very  seldom  Z),  is  implicated.  If  the 
lesion  be  on  the  anterior  portion  of  the  scrotum,  B  and  C  are  in  most 
cases  tlie  glands  mainly  involved.  If  it  be  on  the  leg  or  on  the  lower  part 
of  tiie  thigh,  we  find  that  it  is  first  D  and  then  C  which  is  either  exclu- 


THE    SIMPLE    BUBO.  397 

sively  or  especially  swollen.  In  affections  of  the  buttocks,  it  is  ^  ;  in 
those  of  the  hypogastrium,  A  and  B ;  finally,  in  those  of  the  perinjeum, 
and  of  the  posterior  portion  of  the  scrotum,  whose  lymphatics  unite  with 
each  other  or  with  the  lymphatics  of  the  penis,  it  is  the  group  B  (B  ) 
which  is  chiefly  affected.  The  group  B  is  exclusively  swollen  only  in 
consequence  of  affections  of  the  lower  extremity,  and  never  from  those  of 
the  genitals." 

Data  similar  to  the  above,  with  regard  to  the  anatomical  relations  of 
lesions  and  buboes  in  other  parts  of  the  body,  especially  the  upper  ex- 
tremities, head,  and  face,  where  of  venereaK  ulcers  the  chancre  is  the  rule 
and  the  chancroid  the  exception,  will  be  given  when  describing  the  indu- 
rated bubo. 

The  Simple  Bubo. — As  already  stated,  this  bubo  is  nothing  more  than 
a  simple  adenitis.  Its  causes  are  various.  Commencing  with  those  which 
are  of  the  more  trivial  chai-acter  and  advancing  to  the  graver,  they  may 
be  enumerated  as  follows  : — 

1.  In  the  first  place,  it  may  depend  merely  upon  excessive  sexual  in- 
dulgence. Instances  of  this  kind  are  by  no  means  common,  but  are  occa- 
sionally met  with. 

2.  It  may  be  due  to  any  mechanical  lesion  of  the  genital  organs,  as  a 
rent  or  abrasion  contracted  in  coitus,  especially  if  the  latter  be  subjected 
to  cauterization  or  the  application  of  irritant  dressings. 

3.  It  may  be  due  to  eczema,  herpes,  follicular  inflammation,  balanitis, 
vulvitis,  or  any  other  simple  affection  of  the  genitals.  Such  simple  causes 
as  these  and  those  above  mentioned  are  now  and  then  so  slight  and  so 
transient,  that  they  can  be  ferreted  out  only  by  the  most  careful  investi- 
gation of  the  case,  or  otherwise  the  bubo  passes  for  a  buhon  d'emb/ee. 

4.  Urethritis,  whether  due  to  contagion  or  not,  and  any  mechanical 
lesion  of  the  urethra,  as  by  the  use  of  instruments  or  the  passage  of  a  cal- 
culus, may  occasion  it. 

5.  It  may  depend  upon  the  ])resence  of  a  chancroid,  or  even  a  true 
chancre  or  a  secondary  lesion  of  syphilis,  acting  merely  as  a  common  source 
of  irritation  and  injiammation,  and  not  in  virtue  of  any  virulent  or 
specific  quality. 

The  manner  in  which  either  of  the  above  causes  produces  its  effect  upon 
the  gland  has.  possibly,  not  been  fully  explained,  since  the  intervening 
lymphatic  may  show  no  sign  of  being  involved.  The  old  idea  of  ''  sym- 
pathy" between  the  rootlets  of  the  lymphatics  and  the  ganglion  in  which 
they  terminate  is  no  longer  tenable.  Doubtless,  in  many  cases,  simple 
irritant  matter  is  conveyed  by  them  and  lodged  in  the  ganglion  ;  in  other 
cases^  the  inflammatory  process  probably  extends  through  them,  but  is  so 
transient  and  rapid  in  its  passage  as  to  afford  no  evidence  of  its  having 
existed.  Analogous  instances  are  found  in  the  inflammation  and  suppu- 
ration of  glands  in  other  parts  of  the  body,  as  the  axilla,  in  consequence 
of  wounds  of  the  fingers,  prurigo,  eczema,  etc.,  especially  when  the  irrita- 
tion is  heightened  by  excessive  manual  labor,  as  we  often  see  in  washer- 


398  THE    SIMPLE    AND    THE    VIRULENT    BUBO. 

women.     "NVe  again  observe  the  same  in  tlie  evolution  of  gonorrhceal  epi- 
didymitis witliout  any  affection  of  tiie  cord. 

The  simple  bubo  usually  api)cars  during  the  early  period  of  the  exist- 
ence of  the  lesion  upon  -which  it  depends,  within  a  few  days  or  the  first 
week  or  fortniglit  after  the  appearance  of  the  latter. 

The  symptoms  of  simple  adenitis  are  well  known.  Most  frequently 
only  one  gland  is  affected  ;  if  others  are  involved,  they  are  commonly  so 
to  a  less  degree.  The  patient  first  notices  a  swelling  in  the  groin  attended 
with  tenderness  on  pressure,  and  pain  which  is  aggravated  by  motion  or 
the  standing  posture.  The  gland  is  felt  to  be  somewhat  enlarged,  but  is 
still  movable  beneath  the  integument  which  preserves  its  normal  color ; 
and  the  surrounding  cellular  tissue  is  evidently  thickened  by  infiltration. 
This  condition  may  last  for  an  indefinite  period,  and  yet  finally  disappear 
without  suppuration.  There  exists  only  ganglionic  tension  or  engorge- 
ment, which  undergoes  resolution,  and  this  holds  good  of  the  great  majority 
of  buboes  originating  in  such  simple  causes  as  gonorrhoea,  balanitis,  herpes, 
etc.  ;  whereas  a  simple  bubo  dependent  upon  a  chancroid  is  usually  much 
more  inflammatory  in  its  character  and  prone  to  suppuration. 

In  the  less  fortunate  cases,  the  inflammatory  symptoms  increase  in 
severity ;  the  tumor  acquires  large  dimensions  and  becomes  adherent  to 
the  skin  and  underlying  fascia  so  that  it  is  no  longer  movable;  the  pain 
and  tenderness  are  increased ;  motion  is  difficult ;  the  skin  becomes  red- 
dened ;  suppuration  is  ushered  in  by  a  chill ;  the  presence  of  matter  is 
indicated  by  a  soft  spot  in  the  midst  of  the  general  hardness,  and  soon 
after  by  distinct  fluctuation  ;  and  although  resolution  is  still  possible,  yet 
commonly  the  contents  of  the  abscess  are  discharged  through  an  open- 
ing in  the  integument  formed  by  the  process  of  ulceration.  In  the  great, 
majority  of  cases  I  believe  that  the  seat  of  the  suppuration  is  in  the  cellu- 
lar tissue  surrounding  the  gland  and  not  in  the  gland  itself.  The  original 
congestion  or  inflammation  of  the  glandular  tissue  appears  to  undergo  re- 
solution after  exciting  a  similar  process  in  the  loose  cellular  tissue  of  the 
neighborhood  wliich  more  readily  takes  on  suppurative  action  ;  and  when 
the  abscess  is  opened  by  nature  or  art,  the  gland  may  often  be  seen  within 
the  cavity  already  covered  with  granulations  destined  to  commence  the 
work  of  repair. 

The  pus  of  a  simple  inflammatory  bubo  is  like  that  of  any  cotnmon  ab- 
scess^ destitute  of  contagious  properties,  and  therefore  not  inoculable. 

I  have  spoken  of  the  simple  inflammatory  bubo  as  aflfecting  one  gan- 
glion, but  it  sometimes  happens  that  two  or  more  are  involved,  when 
several  collections  of  matter  may  form,  and  these  by  their  early  union 
may  give  rise  to  one  large  abscess ;  or  they  may  remain  distinct  or  only 
communicate  after  the  opening  of  one  of  them.  Not  unfrequently  these 
collections  of  matter  are  separated  by  Poupart's  ligament,  one  being  situ- 
ated in  the  groin  and  the  other  upon  the  upper  and  inner  part  of  the  thigh. 

The  course  of  a  bubo  subsequent  to  the  evacuation  of  the  contained 
matter  varies  in  different  cases.  In  healthy  subjects  and  under  pioper 
treatment,  the  cavity  may  rapidly  contract  and  fill  with  granulations,  its 


THE    SIMPLE    BUBO.  399 

walls  unite  and  cicatrization  take  place,  leaving  a  slight  scar  scarcely  per- 
ceptible after  the  lapse  of  a  few  months.  In  less  fortunate  cases,  secondary 
abscesses  form  in  the  neighborhood  even  after  the  first  has  been  opened, 
and  communicating  with  the  cavity  of  the  latter,  give  rise  to  fistulous 
passages  which  are  often  several  inches  in  length.  Or  again,  instead  of 
having  a  distinct  point  of  origin,  a  fistulous  track  may  shoot  out  from  the 
cavity  itself.  The  opening  may  have  been  free,  allowing  ample  exit  to 
the  matter,  and  the  process  of  repair  appear  to  be  going  on  propitiously, 
when  suddenly  without  apparent  cause  tlie  surgeon  in  passing  his  finger 
over  the  surface  notices  a  hardened  cord  beneath  the  skin,  or  in  probing 
the  cavity  discovers  a  new  fistulous  track,  which  has  formed  insidiously 
without  giving  the  slightest  indication  of  its  presence.  In  short,  a  line  of 
infiltration  of  the  cellular  tissue  has,  as  it  appears,  started  from  the  original 
abscess,  and  by  a  {)rocess  of  suppuration  opened  anew  fistulous  track  ;  and 
thus  the  cellular  tissue  beneath  the  skin  may  become  riddled  with  false 
passages  of  different  lengths,  running  in  various  directions,  and  reminding 
one  of  the  burrowings  of  a  mole  in  a  hay -field.  In  whichever  mode  de- 
veloped, these  fistulous  tracks  most  frequently  run  along  Poupart's  liga- 
ment either  upwards  and  outwards  towards  the  anterior  superior  spine  of 
the  ilium,  or  downwards  and  inwards  to  the  inne^  fold  of  the  thigh.  In 
rare  instances  they  penetrate  nearly  perpendicularly  to  the  surface  for 
some  distance.  Their  walls  become  covered  with  a  kind  of  false  membrane 
which  secretes  a  thin  purulent  matter,  and  the  surrounding  tissues  are 
more  or  less  brawny  to  the  touch. 

In  strumous  subjects,  a  bubo  often  assumes  a  still  more  sluggish  and 
subacute  character,  resembling  the  well-known  scrofulous  inflammation  of 
the  glands  of  the  neck  in  young  persons. 

Tlie  inguinal  tumor  is  less  firm  and  of  a  more  doughy  feel  than  in  the 
form  above  described.  A  moderate  amount  of  pain,  tenderness  on  pres- 
sure, and  difficulty  of  motion  may  be  complained  of  by  the  patient,  but 
these  are  rarely  severe  or  of  long  continuance.  The  tumor  very  slowly 
enlarges,  perhaps  to  the  size  of  a  hen's  egg,  and  loses  its  mobility  in  con- 
sequence of  contracting  adhesions  to  the  neighboring  tissues.  Tlie  skin 
covering  it  becomes  thin  and  of  a  livid  red  color,  and  fluctuation  can  be 
detected  without  being  ushered  in  by  chills  and  fever,  as  in  the  inflamma- 
tory bubo.  If  an  opening  now  be  made  witii  tlie  lancet,  the  young  surgeon 
is  surprised  to  find  that  notiiing  resembling  ordinary  pus  flows  out,  but 
merely  a  thin,  flaky,  watery-looking  fluid,  li',  on  the  other  hand,  the 
tumor  be  left  to  itself,  several  openings  usually  form  spontaneously  at  dif- 
ferent points  of  the  surface,  and  the  skin  included  between  them,  being 
deprived  of  its  vascular  sup[)ly,  loses  its  vitality  and  gives  way.  The 
gland§  thus  exposed  are  found  to  be  more  or  less  disorganized;  they  are 
of  a  spongy  and  friable  texture,  and  infiltrated  with  thin  purulent  matter 
which  can  be  made  to  exude  upon  pressure  from  the  numerous  openings 
upon  tiieir  surface.  The  external  opening  is  still  further  enlarged  by 
retraction  of  the  skin,  and  tlie  mass  of  swollen  and  disorganized  glands 
often  projects  above  the  level  of  the  surrounding  integument,  iiml,  arting 


400         THE  SIMPLE  AND  THE  VIRULENT  BUBO. 

like  a  foreign  body,  interferes  with  cicatrization  of  the  wound.  Fistulous 
tracks  may  form,  running  in  various  directions,  but  phagedsena  never 
occurs  as  a  complication,  as  it  does  with  a  virulent  bubo. 

Virulent  Bubo The  virulent  bubo  receives  its  name  from  the  fact 

tliat  the  pus  which  it  contains  is  contagious,  and  will,  upon  artificial  in- 
oculation, give  rise  to  a  chancroid.  It  is  in  fact  a  chancroid  of  the  gan- 
glion, and  hence  may  be  called  a  chancroidal  bubo. 

Unlike  tiie  simple  inflammatoiy  bubo,  it  is  due  to  a  single  cause  only, 
viz.,  the  presence  of  a  chancroid  upon  the  region  supplied  by  the  lymphatics 
in  anatomical  connection  with  the  affected  ganglion ;  and,  so  far  as  we 
know,  its  occurrence  cannot,  be  avoided  by  any  precautions  except  by  the 
destruction  of  the  chancroid,  nor  favored  by  any  extraneous  means,  as 
mechanical  violence,  muscular  fatigue,  etc.,  which  play  so  important  a 
part  in  the  etiology  of  the  simi)le  inflammatoiy  bubo. 

The  virus,  secreted  by  the  chancroid  gains  entrance  within  the  lymph- 
atics, probably  by  ei'osion  of  these  vessels,  and  not,  strictly  speaking,  by 
absorption.  Being  conveyed  along  their  course,  it  is  sometimes  arrested 
at  a  certain  point,  and  gives  rise  to  virulent  lymphitis,  which  will  be  de- 
scribed hereafter.  More  frequently  it  reaches  one  of  the  ganglia,  beyond 
which  it  never  extends;  its  further  progress  is  stopped  by  the  intricate 
meshes  and  minute  ramifications  of  this  body,  and  its  presence  gives  rise 
to  inflammation  which  assumes  the  contagious  character  of  the  exciting 
cause.  Tlje  same  power  of  reproduction  is  manifested  which  gives  to 
virulent  pus  its  contagious  qualities,  and  the  abscess  which  necessarily 
ensues  is  filled  with  inoculable  matter.  Resolution  is  as  impossible  and 
su[)|)uration  as  inevitable  as  if  the  secretion  of  tiie  chancroid  had  been, 
deposited  within  the  ganglion  upon  the  point  of  a  lancet.  From  the  sup- 
posed mode  of  ijs  origin,  this  bubo  has  sometimes  been  called  the  hubo 
from  absorption. 

A  virulent  bubo  usually  occurs  during  the  early  or  progressive  stage  of 
a  chancroid,  but  is  by  no  means  confined  to  this  period.  Ricord  refers  to 
a  case  in  tlie  service  of  M.  Puche,  in  which  a  virulent  bubo  made  its 
appearance  as  late  as  three  years  after  the  commencement  of  a  serpiginous 
chancroid. 

The  chancroid  may  liave  entirely  healed  before  the  develo[)ment  of  a 
virulent  l)ubo,  and  the  virus  have  entered  the  lymphatics  but  a  siiort  time 
before  cicatrization  took  place. 

Since  the  chancroid  is,  in  the  great  majority  of  cases,  situated  upon  the 
genital  organs  or  in  their  neighborhood,  a  virulent  bubo  occurs  with  cor- 
responding frequency  in  the  groin.  Even  when  the  chancroid  is  seated 
within  the  male  uretlira,  or  in  the  deeper  portions  of  the  vagina,  or  upon 
the  cervix  uteri,  or  when  in  either  sex  it  exists  upon  the  perinaeum  or  at 
the  anus,  it  is  equally  in  tiie  groin  that  we  are  to  look  for  a  virulent  bubo 
— a  fact  which  has  been  established  by  Ricord,  Robert,  Grivot,  Grand- 
court,  Bernutz,  Legendre,  Langlebert,  and  other  observers.  Artificial 
inoculation  of  the  chancroidal  virus  upon  the  arm  has  produced  virulent 


VIRULENT    BUBO.  401 

buboes  in  tlie  axilla,  and  in  a  case  reported  by  Huebbenet,  one  was  de- 
veloped over  the  parotid  gland  following  an  inoculation  U}  on  the  cheek. 

Virulent  adenitis  is  usually  situated  upon  the  same  side  of  the  median 
line  as  the  chancroid,  but  sometimes  upon  the  opposite,  owing  to  the  inter- 
lacement of  the  lymphatics.  Commonly  only  one  groin  is  affected;  occa- 
sionally both  are  involved,  especially  when  there  are  several  chancroids 
seated  upon  each  side  of  the  penis,  or  when  one  ulcer  is  situated  upon  any 
part  directly  in  the  median  line,  as  the  frivnum.  It  is  very  rare  for  more 
than  a  single  gland  on  one  or  both  sides  to  suppurate  specifically ;  and 
hence  the  virulent  bubo  is  said  to  be  "monoganglial."  Other  ganglia  in 
the  neighborhood  may,  however,  be  secondarily  affected  through  extension 
of  the  inflammatory  process,  but  should  they  suppurate,  the  pus  is  not 
inoculable  like  that  of  the  first  ganglion. 

Prior  to  its  spontaneous  or  artificial  opening,  the  course  of  a  virulent  is 
the  same  as  that  of  a  simple  inflammatory  bubo,  and  the  student  should 
understand  that  the  early  symptoms  of  the  two  are  identical ;  though  the 
presence  of  the  former  may  be  suspected  from  the  rapid  growth  of  the 
tumor  and  its  tendency  to  suppurate  ;  while  the  existence  of  the  latter 
will  be  rendered  probable  by  an  irritated  or  inflamed  condition  of  the 
chancroid  upon  the  genitals,  and  by  an  amelioration  in  the  bubo  following 
rest  and  antiphlogistic  treatment.  Whenever  a  bubo  undergoes  complete 
resolution  without  coming  to  suppuration,  it  is  evident  that  it  could  not 
liave  been  virulent. 

During  the  formation  of  this  bubo,  the  virulent  pus  is  confined  to  the 
interior  of  the  affected  ganglion  ;  but  at  the  same  time  simple  inflamma- 
tion and  suppuration  commonly  take  place  in  the  surrounding  cellular  tis- 
sue as  in  the  simple  inflammatory  bubo,  and  hence  there  exist  two  collec- 
tions of  matter  se[)arated  by  the  walls  of  the  ganglion  ;  the  one  within 
containing  chancroidal,  and  the  one  without  simple  pus.  Now  if  the  bubo 
be  left  to  itself,  the  external  abscess  usually  breaks  before  the  internal, 
and  consequently  the  pus  which  first  flows  out  is  simple  and  not  inocula- 
ble, and  the  cavity  of  the  abscess  may  be  covered  with  healthy  granula- 
tions like  that  of  the  simple  inflammatory  bubo.  In  the  course  of  a  few 
days,  however,  the  glandular  abscess  discharges  its  virulent  matter,  inocu- 
lating the  surface  of  the  cavity,  and  the  latter  puts  on  all  the  characters 
of  a  chancroid  ;  its  interior  becomes  covered  with  a  grayish  diphtheritic 
deposit,  its  edges  are  everted  and  undermined,  and  its  secretion  is  auto- 
inoculable,  or  if  it  accidentally  comes  in  contact  with  any  solution  of  con- 
tinuity, as  a  leech-bite,  in  the  neighborhood,  it  will  give  rise  to  a  chan- 
croid. The  same  can  be  demonstrated  when  opening  the  bubo  artificially  ; 
if  a  superficial  incision  first  be  made  so  as  to  penetrate  the  external  ab- 
scess ort'.y,  and  a  drop  of  the  exuding  matter  be  inoculated;  and  if  sub- 
sequently the  knife  be  made  to  |)enetrate  the  glandular  abscess,  and  some 
of  its  contents  be  also  inserted  beneath  the  epidermis,  it  will  be  found  that 
the  former  inoculation  will  fail  while  the  latter  will  succeed.' 

'  "  Equally  instructive  exatnphs  (that  thn  glands  collect  hurtful   ingredients, 
and  thereby  afford  protection  to  tlie  body)  are  aflbrded  by  the  history  of  syphilis, 
26 


402  THE    SIMPLE    AND    THE    VIRULENT    BUBO. 

Secondary  abscesses  may  form  in  the  vicinity  of  the  gland  first  affected 
in  the  virnlent,  as  in  the  simple  inflammatory  bubo,  but  virulent  pus  does 
not  appear  except  as  the  result  of  inoculation  from  the  original  abscess. 
Again,  fistulous  passages  may  be  produced  in  the  manner  already  de- 
scribed ;  these  have  been  known  to  result  in  very  extensive  underminings 
of  the  skin,  attended  by  acute  inflammation  of  the  cellular  tissue,  of  the 
most  formidable  character.' 

In  some  instances,  a  virulent  bubo  heals  kindly  in  the  coui'se  of  a  few 
weeks,  like  the  milder  chancroids  upon  the  genitals  previously  described. 
It  is  thus  probable  that  many  virulent  buboes  are  never  recognized  as 
such,  since  their  appearance  may  not  attract  the  attention  of  the  attendant 
physician,  and  the  only  unfailing  test  of  their  existence — auto-inoculation 

is  rarely  applied,  or  even  necessary.     But  there  is  another  termination 

which  is  far  less  fortunate,  and  which,  although  not  frequent,  is  one  of  the 
most  fearful  consequences  of  venereal  exposure  : — 

Vindent  adenitis^  alone  of  the  different  forms  of  bubo,  is  liable  to 
phagedcena. 

In  a  few  cases  this  complication  would  appear  to  follow,  and  perhaps 
depend  upon,  that  of  the  chancroid  upon  the  genitals,  phagedsena  existing 
in  both  ;  but,  in  the  majority,  phagednena  attacks  the  inguinal  chancroid 
or  bubo,  when  the  original  sore  has  shown  no  such  tendency,  or  has  even 
been  of  the  mildest  type. 

The  I'emarks  already  made  with  regard  to  phagedaena  in  connection 
with  the  chancroid  apply  here.     It  may  appear  in  three  forms  : — 

1.  Limited  in  extent  and  duration  ;  merely  enlarging  the  boundaries  of 
the  abscess,  or  at  most  increasing  its  depth  and  persistency,  but  soon 
yielding  to  appropriate  treatment. 

2.  Sloughing  phagedasna,  resembling  hospital  gangrene,  a  rare  form 
when  accompanying  a  bubo;  and 

.3.  Serpiginous  phagedaina,  to  the  extent  and  duration  of  which  there  is 
no  limit. 

The  last-named  form  is  the  source  of  those  persistent  and  disgusting 
serjuginous  ulcers  which  we  occasionally  see  in  our  public  hospitals,  and 
which  are  depicted  in  all  sets  of  illustrations  of  venereal  diseases.  (See 
Ciillericr's  Atlas,  pi.  xv.) 

.Judging  from  my  own  observation,  these  ulcers  commence  in  a  viru- 
lent bubo  far  more  frequently  than  in  a  chancroid  upon  the  genitals. 
Their  symptoms    have  already  been  described  in  the  preceding  chapter, 

in  which  a  bubo  may  for  a  time  become  tlie  depository  of  the  poison,  so  that  the 
rest  of  the  economy  is  affected  in  a  comparatively  trifling  degree.  As  Ricord  has 
stiown,  it  is  precisely  in  the  interior  of  the  real  substance  of  the  gland  that  the 
viruleut  matter  is  found,  whilst  the  pus  at  the  circumference  of  the  bubo  is  free 
fi-om  it;  only  so  far  as  the  parts  come  into  contact  witli  the  lymph  conveyed  from 
the  diseatied  part,  do  they  absorb  the  virulent  mattcir."  (Virchow,  Cellular  Puth- 
olof/ij,  p.  187.) 

'  See  a  remarkable  case  reported  by  Debauge,  Chancres  simples  et  bubons  chan- 
'•n-ux,  These  de  Paris,  JSfjS,  p.  75. 


VIRULENT    BUBO. 


403 


and    their  possible  severity  is  shown   in  the  following   case  reported  by 
Foiirnier :' — 

"  A  deplorable  instance  of  ganglionic  phagedaMia  was  to  be  seen  in  the 
wards  of  M.  Eicord,  in  1856.  The  patient  had  contracted,  in  1849,  a 
simple  chancre  on  the  penis,  which  healed  readily  itself,  but  which  was 
complicated    with  an  acute    bubo.     This    bubo    suppurated,  opened,  and 

Fig.  115. 


Phagetleuic  bubo.     (After  Jullien,  op.  cit.  p   4.'?.S.) 

continued  for  several  weeks  without  showing  any  tendency  to  increase  in 
size,  but  suddenly  the  inguinal  ulceration  began  to  extend,  and  took  on 
the  character  of  serpiginous  phagedajna.  From  that  time,  in  spite  of 
every  mode  of  treatment,  and  of  the  most  energetic  means  known  to 
science,  this  ulcer  still  extended;  it  invaded  the  whole  inguinal  region, 
turned  the  flank,  mounted  towards  the  loins,  and  entirely  covered  one 
buttock  ;  then  it  descended  again  upon  tlie  thigh,  the  posterior  and  ex- 
ternal surface  of  wliich  it  ploughed  up  for  tiie  whole  extent  of  the  limb, 
and  at  Jast  readied  below  tiie  knee,  where  it  finally  sprea<l  out  over  an 
enormous  surface.  Everything  was  done  for  this  horrible  sore,  but  all 
means  failed.  The  patient  left  the  hospital  without  benefit  and  wholly 
discouraged.  Many  years  after,  I  met  this  unfortunate  in  one  of  the 
streets  of  Paris,  i)ale,  emaciated,  and  scarcely  able  to  drag  himself  alojig. 


'  N.  Diet,  (le  m^d.  et  de  cliir.  prat.,  Paris,  t.  v,  p.  771. 


404  THE  SIMPLE  AND  THE  VIRULENT  BUBO. 

He  told  me  that  lie  had  hecn  sid)jected  to  various  modes  of  treatment, 
without  success,  and  that  his  ulcer  was  still  present.  Moreover,  his  leg 
was  Hexed  at  a  right  angle  upon  the  thigh  through  retraction  of  the  cica- 
trices on  the  posterior  aspect  of  the  knee.  The  disease  had  now  lasted 
for  fourteen  years!" 

CoMri.TCA Tioxs. — On  account  of  the  anatomical  situation  of  the  in- 
guinal ganglia,  lying  in  loose  connective  tissue  and  in  the  vicinity  of  im- 
portant vascular  connections,  buboes  in  this  region,  especially  after  having 
been  laid  open  and  thus  deprived  of  the  support  of  the  integument,  are 
exposed  to  various  forms  of  hemorrhage,  which  have  been  studied  at 
length  in  an  able  article  by  Dr.  De  Paoli.'  According  to  this  author,  the 
hemorrhage  may  assume  three  forms. 

1.  It  may  take  place  in  the  connective  tissue  surrounding  the  gland,  in 
which  case  the  serum  of  the  extravasated  blood  may  be  seen  to  ooze  from 
the  edges  of  the  wound  or  may  be  forced  out  in  a  jet  on  pressure,  leaving 
the  solid  constituents  behind  to  be  absorbed  ;  or,  in  case  the  effusion  has 
been  large,  inflammatory  action  is  set  up,  and  an  abscess  is  formed  which 
finally  communicates  with  the  original  one  by  means  of  a  fistulous  track, 
or  opens  through  the  overlying  skin. 

2.  Tiie  hemorrhage  may  take  place  from  the  surface  of  the  bubo,  even 
when  the  latter  has  been  progressing  favorably  with  a  prospect  of  speedy 
cicatrization. 

3.  Further,  De  Paoli  speaks  of  what  he  calls  a  hemorrhagic  hnho,  a 
form  which,  it  appears,  is  not  uncommon  among  the  impoverished  residents 
of  the  large  cities  of  Italy.  In  this  form,  a  tumor  is  developed  in  the 
groin  and  gradually  enlarges  without  [)roducing  much  swelling  externally. 
The  skin  covering  it  is  of  a  rose-red  color,  somewhat  darker  at  the  centre. 
Fluctuation  is  detected  on  palpation,  but  it  is  evident  that  the  amount  of 
matter  is  not  proportionate  to  the  extent  of  the  undermining  of  the  integu- 
ment. The  patient  suffers  little  inconvenience,  and  probably  pursues  his 
ordinary  avocation. 

Following  the  act  of  coughing,  or  on  straining,  or  even  without  appre- 
ciable cause,  this  swelling  undergoes  a  sudden  increase  of  size.  W  incised, 
a  moderate  amount  of  blood  escapes,  and  an  extensive  cavity  is  exposed, 
covered  with  fungosities  of  a  bluish  color,  with  one  or  more  hyperplastic 
glands  at  the  centre.  These  latter,  if  cut  into,  bleed  freely.  The  sur- 
rounding integument  is  found  to  be  extensively  detached,  thinned,  and 
ecchymosed.  The  vascular  bands  or  bridles  connecting  the  opposite  walls 
of  the  abscess,  which  are  usually  found  in  the  purulent  bubo,  are  here 
com|)letely  wanting. 

Even  after  free  incision,  little  tendency  is  shown  towards  reparative  ac- 
tion. Fungous  granulations  spring  up,  which,  on  the  slightest  occasion, 
as  a  fit  of  coughing  or  the  application  of  almost  any  dressing,  break  down 

'  Gior.  ital.  d.  mal.  ven.,  Milaiio,  1874. 


BUBON  d'emblee.  405 

again  and  bleed  freely,  and  the  case  is  often  aggravated  by  the  formation 
of  ecchymoses  in  the  neigliborhood. 

De  Paoli  has  observed  this  bubo  in  persons  of  a  decidedly  scrofulous  or 
phlegmatic  temperament,  but  most  frequently  in  those  affected  with  scurvy, 
of  which  it  is  often  one  of  the  first  manifestations,-^"  not  indeed  the  terri- 
ble form  of  scurvy  which  affects  mariners,  but  the  milder  form  met  with 
among  tlie  impoverished  residents  of  the  slums  of  large  cities." 

Dr.  Hammond  mentions  a  case  of  death  from  pyaemia  following  the 
opening  of  a  bubo  (op.  cit.  p.  TiT).  Prof.  B.  W.  McCready  has  met  with 
a  sloughing  bubo,  0])ening  into  the  bladder  and  giving  rise  to  a  urinary 
fistula.      (Oral  com.) 

A  bubo  sometimes  occasions  peritonitis,  which  is  usually  partial,  but 
which  may  become  general.  Clerc^  gives  two  such  fatal  cases,  including 
the  post-mortem  appeax'ances. 

The  possibility  of  a  bubo  being  transformed  into  a  cancerous  ulcer  is 
admitted  by  Jullien  (op.  cit.  p.  4.38),  who  quotes  Rollet  as  having  met 
with  such  a  case  in  an  old  man. 

An  instance  is  reported  by  De  Paoli,  in  which  the  inflammatory  process 
extended  from  a  bubo  in  tlie  groin  to  a  testicle  retained  in  the  corresponding 
inguinal  canal. 

BuBON  d'emblee(?). — The  older  writers  on  venereal  diseases  believed 
tliat  the  chancroidal  and  syphilitic  poisons  could  be  absorbed  without  any 
lesion  of  the  skin  and  without  any  sore  apj)earing  at  the  point  of  absor|)tion. 
In  this  manner,  they  stated  there  might  occur  a  '■'■habon  d'emblee,'"  or  "non- 
consecutive  bubo."  arisiiig  inde[)endently  of  any  lesion  of  the  genital  organs, 
secreting  pus  which  was  auto-inoculable,  and  capable  of  being  followed  by 
general  syphilitic  infection  of  the  system.  Within  tlie  present  century  this 
view  has  been  advocated  by  Baunies,  Casteliiau,  Bertherand,  Cazenave, 
and  Vidal  de  Cassis,  partly  also  by  Diday ;  and  has  been  ably  opposed  by 
Kicord,  Fournier,  Rollet,  Langlebert,  Yirchow,  and  others.  None  of  the 
cases  aflduced  in  its  favor,  not  forgetting  one  published  by  Molliere,^  which 
attracted  at  the  time  considerable  attention,  and  which  made  a  convert  of 
Diday,  can  be  regarded  as  convincing. 

In  short,  there  is  as  yet  no  proof  whatever  that  the  chancroidal  or  syph- 
ilitic poison  can  be  absorbed  through  the  sound  integument  and  no  local  reac- 
tion occur  at  the  point  of  inoculation.  A  bubo  secreting  inoculable  pus  can 
depend  only  upon  a  chancroi<l  situated  either  externally  or  coneeah'd  witliin 
a  mucous  canal,  as  the  uretiira,  vagina,  or  rectum.  This  chancroid  may 
escape  observation,  either  on  account  of  its  having  healed  at  the  time  the 
y)atient  comes  under  observation  or  because  it  is  not  sufficiently  sought  for, 
liut  it  ftMist  exist  or  have  existed.  Until  more  satisfactory  evidence  is  ad- 
duced in  its  favor,  we  must  conclude  tliat  the  existence  of  a  "  l)ul)(tn 
d'emblee"  is  not  proven. 

'  Ann.  (It!  (icrm.  et  sypli.,  Paris,  t.  i,  1800,  p.  430. 

2  D.  MoLLifcKK,  Of)servation  de  bubon  d'embl6e  cliancrelloux,  Lyon  nietl,,  1873, 
t.  1,  pp.  22(),  241,  320. 


406  THE    SIMPLE    AND    THE    VIRULENT    BUBO. 

Diagnosis  of  Buboks It  is  rarely  the  case  that  a  bubo  can  be  mis- 
taken bv  an  intelligent  observer  for  any  other  affection,  and  little  more 
tlian  mere  mention  of  the  possible  sources  of  error  will  be  called  for. 

Hernia  will  be  recognized  by  the  softness  of  the  swelling,  by  the  im- 
pulse conveyed  on  coughing  or  sneezing,  by  its  disappearance  on  pressure 
or  on  assuming  the  recumbent  posture,  by  its  increase  when  the  patient  is 
standing,  by  the  absence  of  tenderness  and  other  symi)toms  of  inflamma- 
tion. In  case  the  hernia  is  irreducible,  w^e  still  find  resonance  on  percus- 
sion, and,  should  strangulation  occur,  the  constipation  of  the  bowels,  the 
fecal  vomiting,  the  tenderness  of  the  abdomen,  and  the  grave  general 
svmptoms  which  rapidly  ensue,  will  probably  \)\\i  the  attending  surgeon 
on  tlie  right  track  ;  we  say  "probably,"  because  a  bubo  alone  may  set  up 
peritonitis,  the  cause  of  which,  however,  is  not  likely  to  be  mistaken, 
unless  by  a  careless  observer. 

An  undescended  testicle,  inflamed  in  the  course  of  a  gonorrhoea,  may  be 
mistaken  for  a  bubo.'  The  diagnosis  may  be  based  on  the  following 
points : — 

1.  Absence  of  the  testicle  from  the  scrotum  on  the  aflTected  side. 

2.  The  presence  in  the  inguinal  canal  of  a  movable  tumor,  ovoid  in 
form,  smaller  than  the  descended  testicle,  but  giving  the  cliaracteristic 
pain  on  pressure. 

3.  The  inflamed  tumor  is  seated  above  Poupart's  ligament,  and  its  long 
axis  corresponds  with  that  of  the  inguinal  canal. 

4.  The  tumor  is  separable,  on  manipulation,  into  two  portions,  one 
inferior  and  internal,  larger,  harder,  and  more  irregular,  which  is  the  epi- 
didymis ;  the  other,  su|ierior  and  external,  smaller,  ovoid,  smoother  and 
softer,  which  is  the  testicle. 

Injiammaiion  of  the  cord  due  to  gonorrluca  rarely  occurs  without  the 
epididymis  on  the  same  side  being  also  affected.  Should  it,  however, 
occur  alone,  the  coexistence  of  the  urethral  discharge,  the  position  of  the 
swelling,  its  diffuse  character,  and  the  very  considerable  amount  of  pain 
and  uneasiness  which  it  occasions — far  greater  than  that  caused  by  a 
gonorrlujcal  bubo — will  serve  to  distinguish  it. 

Vari.r  of  the  internal  saphena  imn,  at  the  point  where  it  passes  through 
the  sajilifnic  opening  in  the  fascia  lata  a  short  distance  below  Poupart's 
ligament,  is  said  to  have  been  mistaken  for  a  bubo  as  well  as  for  a  femoral 
liernia.  According  to  Zeissl,^  the  swelling  in  varix  rises  and  falls  iso- 
chronously  with  inspiration  and  expiration  ;  or,  if  the  walls  of  the  vein 
are  so  thickened  that  this  motion  cannot  be  perceived,  the  diagnosis  may 
be  made  out  in  the  following  manner:  If  the  vein  be  compressed  by  the 
fingers  l>elow  the  varix,  the  supply  of  blood  will  be  cut  off,  and  the  tumor 
colhipse  ;  if  the  same  be  done  above  tlie  varix,  the  tumor  will  become 
more  teJise  and  prominent. 

'  S.-.!  two  casos  loported  hy  Rollct,  Gaz.  d.  hop.,  Paris,  3  dec,  1861,  no.  141, 
2  0[,.  fit.,  vol.  i,  p.  228. 


TREATMENT    OF    BUBOES.  407 

An  ulcerated  epithelioma  of  the  groin,  which  often  accompanies  epithe- 
lial cancer  of  the  penis,  may  closely  resemble  a  phagedenic  bubo.  The 
diagnostic  signs  have  already  been  given,  when  speaking  of  the  chancroid. 

Is  it  possible  that  any  one  should  fail  to  distinguish  between  a  bubo  and 
a  simple  abscess,  an  aneurism  or  a  dislocation  of  the  thigh  ? 

Diagnosis  between  the  Simple  and    Virulent   Buboes There    is    no 

certain  means  of  diagnosis  between  a  simple  and  virulent  bubo  on  their 
first  appearance.  If  tiie  jiatient  has  simply  a  gonorrhoea,  balanitis,  herpes, 
eczema,  or  a  mere  abrasion,  a  supervening  bubo  can  of  course  be  only  a 
sinijde  bubo.  If  he  has  a  chancroid,  the  bubo  may  be  either  simple  or 
virulent.  We  find,  in  general,  that  a  simple  bubo  appears  during  the  first 
fortnight  of  the  existence  of  the  cause  upon  which  it  depends,  a  virulent 
bubo  after  this  period;  that  a  virulent  bubo  is  ushered  in  with  more  acute 
symptoms,  as  a  chill,  pain,  and  febrile  disturbance  ;  moreover,  the  glandu- 
lar tumor  is  more  circumscribed,  and  presents  a  hardness  and  elasticity 
which  are  not  met  with  in  the  simple  bubo.  The  virulent  bubo  also 
hastens  with  greater  rapidity  and  witli  certainty  to  suppuration. 

When  a  virulent  bubo  is  left  to  open  itself  or  is  opened  by  the  knife, 
the  contained  pus  is  found  to  be  thick  and  creamy ;  the  secretion  of  a 
simple  bubo,  on  the  contrary,  is  usually  thin,  watery,  and  fiocculent. 
Auto-inoculation  of  the  secretion  of  a  virulent  bubo,  provided  the  matter 
be  taken  from  the  cavity  of  the  gland  itself,  will  produce  a  pustule  followed 
by  a  chancroidal  ulcer;  inoculation  of  the  matter  of  a  simple  bubo  will 
fail.  Finally,  when  the  bubo  is  virulent,  the  whole  surface  of  the  incision 
becomes  inoculated  by  the  virus  discharged  from  the  gland,  and  the  sore 
presents  those  characteristics  which  have  alrea<ly  been  described  as  belong- 
ing to  the  chancroid,  and  a  chancroid  it  really  is,  liable  to  all  the  acci- 
dents of  the  latter,  especially  phagedajna,  and  subject  to  the  same  treat- 
ment. 

When  a  patient  has  a  bubo  in  each  groin,  it  may  be  that  the  one  on  one 
side  is  simple  while  the  one  on  the  other  is  virulent,  as  observed  by  Ricord 
and  others. 

The  diaguosis  between  the  two  forms  of  bubo  here  mentioned  and  the 
induration  of  tlie  ganglia  dependent  upon  syphilis,  will  be  given  in  the 
cha|)ter  on  the  evolution  of  syphilis.  It  should  here,  however,  be  observed 
that  we  may  have  a  bubo  of  a  double  character,  just  as  we  have  sometimes 
a  "mixed  chancre."  For  instance,  a  true  chancre  upon  the  genitals  occa- 
sions induration  of  the  inguinal  ganglia  ;  this  fact  does  not  protect  the 
same  ganglia  from  taking  on  infiamrnation  and  suppuration  in  conseipience 
of  any  of  the  siniple  causes  already  mentioned — and  tliis  is  known  to  be  of 
not  very  unfrequeut  occurrence, — nor  is  there  any  reason  why  a  chancroid 
coexisting  upon  the  genitals  should  not  excite  in  the  same  ganglia  viru- 
lent (chancroidal)  inflammation. 

Treatment  OK  Buhoes A  patient  with  any  affection  of  the  genital 

organs  will  best  avoid  a  bubo  by  remaining  as  quiet  as  possible — abstaining 
from  mucli  exercise  of  any  kind;  by  using  a  suspensory  bandage  when  on 


408  THE    SIMPLE    AND    THE    VIRULENT    BUBO. 

liis  feet  and  keepinj^  tlie  parts  elevated  upon  the  abdomen  when  in  bed  ; 
by  a  liglit  diet  and  the  avoidance  of  stimulants,  and  by  securing  freedom 
of  the  bowels.  To  the  same  end,  the  surgeon  will  take  care  neither  to 
irritate  the  lesion,  whatever  it  may  be,  upon  the  genitals,  by  inappropriate 
dressings  or  applications,  nor  to  abrade  its  surface  and  thereby  lay  open 
channels  for  absorption.  This  remark  does  not  conflict  with  the  use  of  one 
of  the  stronger  caustics  in  the  early  stage  of  a  chancroid,  when  its  employ- 
ment may  be  expected  to  destroy  the  virulence  of  the  ulcer  and  render  the 
absorption  of  virulent  pus  impossible.  Thus  much  as  to  the  prophylaxis 
of  buboes. 

Supposing  a  bubo  to  have  made  its  appearance,  what  then  ?  In  the 
first  place,  let  the  young  surgeon  remember  that  any  attempt  to  abort  it 
can  be  successful  only  in  case  the  bubo  is  a  simple  inflammatory  one  ;  in 
case  it  is  a  virulent  bubo,  the  attempt  will  surely  fail.  Some  weight,  there- 
fore, should  be  attached  to  the  affection  or  lesion  on  which  the  bubo  de- 
pends. If  this  be  a  gonorrha^a  or  balanitis,  an  eruption  of  herpes,  or  other 
simple  affection,  we  are  encouraged  to  use  every  means  to  effect  resolution 
of  the  tumor,  and  shall  often  succeed  unless  the  patient  be  of  a  miserable, 
strumous  constitution.  But  even  if  the  patient  have  a  chancroid,  his  bubo 
may  still  be  simple,  and  hence  attempts  to  abort  it  are  not  absolutely  con- 
traindicated,  but  need  not  be  persisted  in  beyond  a  reasonable  period. 

Abortive  Measures. — Of  all  available  means  to  effect  resolution  of  a  bubo 
and  to  avert  su|)puration,  rest  is  of  the  first  importance,  and  the  more  ab- 
solute it  is  the  better.  Walking  and  even  standing  should  be  avoided,  and 
the  recumbent  posture  be  maintained,  with  the  hips  elevated  by  means  of 
a  cushion  or  pillow.  An  active  cathartic  at  the  outset  will  rarely  be  amiss, 
and  an  evacuation  from  the  bowels  should  be  obtained  daily.  If  the  patie:Tt 
be  of  full  habit,  his  diet  should  be  low  ;  but  when  the  system  is  already 
depressed  or  cachectic,  strict  abstinence  will  favor  su[)puration,  and  should 
l)e  avoidecl. 

Similar  rules  should  govern  the  use  of  local  dejdetion,  the  benefit  from 
which,  however,  is  so  uncertain  as  scarcely  to  compensate  for  its  incon- 
venience; yet  when  the  patient  is  plethoric,  and  the  local  symptoms  acute, 
from  six  to  a  dozen  leeches  may  be  applied  near  (not  upon)  the  tumor,  and 
the  bleeding  be  promoted  l)y  immersion  in  a  hot  bath  ;  but  le(!clies  should 
never  be  used  when  an  abscess  has  formed  and  is  upon  the  jioint  of  open- 
ing, lest  their  bites  be  inoculated  and  transformed  into  chancroids,  in  case 
the  bubo  be  of  the  virulent  kind. 

Tlie  application  of  ice  or  of  ice-cold  compresses  to  the  swelling,  espe- 
cially when  it  is  of  an  acute  inflammatory  type,  will  sometimes  be  success- 
ful in  aborting  a  bubo.  So  long  as  it  is  agreeable  to  the  patient's  feelings, 
it  may  be  regarded  as  beneficial. 

Of  local  applications,  used  as  counter-irritants,  none  is  more  convenient 
nor  perhaps  more  efficacious  than  the  tincture  of  iodine.  It  is  desirable, 
however,  to  use  a  stronger  preparation  than  the  ordinary  tincture  of  the 
Dispensatory,  as  Churchill's,  the  formula  for  which  is  the  following: — 


TREATMENT    OF    BUBOES.  409 

H.     lodinii  Puri  §iiss 75 

Potassii  lodidi  §ss 15 

Spt.  Rectificat.  fgxij 360 

Alcohol  f§iv 120 

Solve. 

The  tinctura  iodinii  decolorata  may  also  be  used,  when  staining  of  the 
skin  must  necessai'ily  be  avoided.  Again,  the  following  ointment  is  a 
valuable  counter-irritant : — 

I^.     Potassii  lodidi  ^j 1  'lO 

lodinii  gr.  v 30 

Unguenti  Adipis  ^j        30 

M. 

Or  a  solution  of  iodine  in  glycerine: — 

R.     Potassii  lodidi  Jss 2 

lodinii  5.) 4 

Glycerinse  §j 38 

M. 

Either  of  these  preparations  may  be  applied  twice  a  day  until  as  much 
inflammation  is  induced  as  the  patient  can  well  bear,  when  the  application 
must  be  less  frequent. 

For  the  purpose  of  lessening  the  irritation  produced  by  the  tincture  of 
iodine,  Prof.  Sigmund  adds  the  tincture  of  nut-gall,  and  Prof.  Zeissl  the 
tincture  of  belladonna  (Zeissl,  op.  cit.  p.  231): — 

R.     Tinct.  lodinii  §j 30] 

Tinct.  Galhe  §.ss 151 

M. 

R.     Tinct.  lodinii  5vj 24 

Tinct.  Belladonnse  5ij 8 

M. 

Zeissl,  however,  extols  the  basic  lead  acetate  in  the  highest  terms  as  a 
substitute  for  iodine  in  the  local  treatment  of  bubo.  His  method  is  to 
soak  three  or  four  compresses  in  a  solution  of  the  acetate  of  lead  and  bind 
them  upon  the  tumor,  wetting  them  again  with  the  same  as  often  as  they 
become  dry.  Dr.  Patzelt'  confirms  this  high  recommendation  after  a  trial 
of  the  lead  acetate  in  sixty-seven  cases. 

Goulard's  extract  is  a  solution  of  the  basic  acetate  of  leatl,  and  may  be 
used  for  this  purpose.  My  opportunities  for  trying  it  have  not  been  suffi- 
cient to  enable  me  to  express  a  decided  opinion  as  to  its  effect,  but  I  cannot 
forbear  stating  my  belief  that  no  special  virtue  is  to  be  found  in  this  or  in 
any  other  of  tiie  topical  applications  here  mentioned.  Counter-irritation  is 
doubtless  of  value,  but,  with  a  commencing  bubo,  rest  is  the  main  thing 
after  all. 

A  strong  solution  of  the  solid  crayon  of  nitrate  of  silver  is  highly  recom- 
mended by  Sir  Henry  Thompson.^  The  strength  of  tiie  solution  is  three 
drachms  of  the  nitrate  of  silver  to  the  ounce  of  water,  with  the  addition  of 

'  Arch.  f.  d.irmat.  n.  syph.,  Prag,  5  Jalirg.  1873,  4  Il.-ft. 
2  London  Lancet,  Am.  «Hi.,  June,  1855,  y.  53G. 


410  THE    SIMPLE    AND    THE    VIRULENT    BUBO. 

twenty  minims  of  strong  nitric  acid.  This  is  freely  applied  to  the  whole 
surface  of  the  tumor,  and  repeated  as  soon  as  the  eschar  comes  away;  or 
the  solid  nitrate  of  silver  may  be  employed  by  first  moistening  the  part 
with  water  and  then  rubbing  the  crayon  for  a  few  minutes  upon  it. 

The  application  of  a  blister — first  shaving  the  part — is  also  resorted  to. 
Diday  recommends  I'eviving  the  blistered  surface  as  it  commences  to  heal 
l)y  pencilling  it  with  tiie  silver  nitrate  in  stick. ^ 

liicord  recommends  that  the  blister  should  be  dressed  twice  a  day  with 
half  a  drachm  of  strong  mercurial  ointment,  and  be  covered  with  a  rye- 
meal  poultice  which  is  to  be  changed  three  or  four  times  in  the  twenty- 
four  hours.  Any  ointment  containing  mercury  should,  however,  be  used 
with  great  caution;  I  have  known  three  ap[)lications  to  a  bubo  to  produce 
very  severe  salivation.  A  caustic  solution  of  the  bichloride  of  mercury, 
proposed  by  MM.  Malapert  and  Reynaud  for  the  treatment  of  buboes  after 
suppuration  has  taken  place,  has  also  been  employed  by  some  surgeons  for 
the  pur[)0se  of  inducing  resolution. 

A  few  years  since  a  favorite  mode  of  treatment  of  subacute  buboes  in 
tlie  French  hospitals  was  by  means  of  "  cauterisation  ponctuee,"  or  the 
ra])id  application  of  a  pointed  iron  heated  to  a  white  heat  to  numerous 
points  over  the  tumor.  The  dread  rather  than  the  pain  of  the  application, 
which  does  not  exceed  that  produced  by  many  caustics,  interferes  Avith  its 
adoption  in  private  practice. 

Compression  is  another  means  employed  to  induce  resolution  of  buboes, 
and  is  said  to  have  been  suggested  by  the  observation  that  these  tumors 
do  not  occur  wherever  a  truss  is  worn.  The  most  ready  metiiod  of  applying 
pressure  is  by  means  of  compressed  sponge  and  a  spica  bandage,  and  the 
ap[)lication  of  hot  water  to  cause  the  sponge  to  swell.  An  Interne  of  th"^ 
Ilopital  du  Midi  invented  a  truss  or  pad  for  the  same  purpose,  consisting 
of  a  rounded  piece  of  wood  covered  with  leather,  and  provided  with  straps 
to  pass  round  the  waist  and  thigh.  This  may  be  obtained  at  most  instru- 
ment niak<!rs,  and  is  very  convenient  and  serviceable.  It  is  generally 
called  "  Ricord's  pad  for  buboes."  Reynaud'^  combines  heat  and  pressure 
by  heating  the  lialf  of  a  common  brick,  the  edges  of  which  have  been 
ciiipped  off,  wrapping  it  in  a  napkin,  laying  it  upon  the  bubo,  and  changing 
it  at  the  end  of  three  or  four  hours,  or  as  soon  as  it  becomes  cool. 

Tiie  application  of  collodion,  which,  by  its  power  of  contraction,  exerts 
pressure  upon  the  tumor,  has  been  recommended  by  Dr.  J.  II.  Clairborne 
and  others. 

Methods  of  Opening  Buboes — So  soon  as  matter  can  be  detected,  and 
it  is  evident  tliat  resolution  is  impossible,  the  abscess  should  at  once  be 
opened.  Delay  will  allow  the  pus  to  collect  and  undermine  the  skin, 
which,  becoming  thin  and  deprived  of  its  vascular  supply,  will  be  destroyed 
to  a  greater  or  less  extent,  thereby  increasing  the  difficulty  of  cicatrization 
and  adding  to  the  dimensions  of  the  unsightly  scar. 

'  Ann.  do  derm,  et  syph.,  Paris,  1  annfie,  1869,  p.  64. 
*  Traite  des  maladies  v^uerienues,  p.  76. 


TREATMENT    OF    BUBOES.  411 

But  even  before  the  presence  of  matter  is  evinced  by  fluctuation,  valu- 
able time  will  often  be  saved  by  an  early  resort  to  the  knife,  and  this  is 
the  case  when  abortive  means  show  no  prospect  of  success,  and  especially 
if  we  have  reason  to  believe  that  we  have  in  hand  a  virulent  bubo,  which 
must  necessarily  terminate  in  suppuration.  Under  these  circumstances, 
no  method  of  procedure  can,  I  believe,  equal  that  proposed  by  Auspitz, 
which  is  most  simple  in  its  performance,  which  can  do  no  harm  even  if  it 
should  prove  to  have  been  uncalled  for,  and  which  will  often  be  found  of 
invaluable  service  in  averting  extensive  suppuration  and  degeneration  of 
the  gland  and  neighboring  tissues.  It  is  based  on  the  philosophical  idea  of 
removing  '•  the  thorn  in  the  flesh"  at  the  earliest  possible  moment,  and  it 
is  described  as  follows  by  its  able  author  : — 

"  As  soon  as  I  can  feel  and  gi-asp  the  hardened  and  somewhat  painful 
gland, — and  this  is  often  as  early  as  the  patient  first  complains  of  jiain  in 
the  groin, — T  press  it  between  the  thumb  and  forefinger  of  the  left  hand 
towards  the  skin,  and  make  a  puncture,  with  a  sharp,  narrow  bistoury, 
perpendicularly  over  the  most  prominent  point  of  the  swelling,  no  deeper, 
however,  than  is  necessary  for  me  to  feel  certain  that  I  have  simply  pene- 
trated the  skin.  I  then  lay  aside  the  bistoury,  and  enter  the  wound  with 
a  thin  bulbous-pointed  probe,  still  keepiny  up  the  pressure  exercised  by  the 
left  hand.  The  point  of  the  probe  sometimes  strikes  against  the  underly- 
ing fascia  superficialis,  which  however  will  give  way  without  the  least  use 
of  force.  In  most  cases  this  fascia  has  been  cut  through  together  with  the 
skin,  and  the  probe  penetrates  immed'ately  into  the  deeper  part  of  the 
g'jtnd,  which  offers  little  resistance.  When  sure  that  the  probe  is  within 
tiie  gland,  I  move  its  point  about  with  a  prying  or  lever-like  motion  in  all 
directions,  and  thus  bluntly  tear  up  the  connective  tissue.  Tiiis  excites 
only  moderate  jiain,  and  does  not  require  much  force.  In  most  cases  a 
small  quantity  of  matter  appears  either  on  the  first  introduction  of  tiie 
sound  or  after  the  completion  of  the  above  movements. 

"  The  gland  being  still  firmly  held  in  the  left  hand,  the  probe  is  now 
withdrawn  and  the  pressure  with  the  left  hand  somewhat  increased  and 
directed  concentrically  against  the  tumor.  The  effect  of  this,  no  matter 
whether  matter  has  been  let  out  or  not,  is  almost  always  an  immediate  and 
very  marked  diminution  in  the  size  of  the  gland  and  a  subsidence  of  the 
pain.  I  have  never  met  with  bleeding  after  this  proceeding  and,  if  it  should 
occur,  it  could  readily  be  controlled. 

"To  comphite  the  operation,  I  apply  to  the  point  of  puncture  a  pledget 
of  carboliz(;d  lint,  and  exert  pressure  U])on  tlie  tumor  by  means  of  com- 
presses and  a  suitable  bandage.  This  dressing  is  allowed  to  remain  for 
twenty-four  hours,  when,  after  again  lightly  pressing  the  tumor  to  force 
out  any  matter,  it  is  renewed.  In  many  cases,  in  the  course  of  forty-eight 
or  even  twenty-four  hours,  it  will  \w  found  that  {\w  ])uncture  has  closed, 
the  gland  shrunk  to  a  small  hardish  lump,  and  the  pain  has  disappeared. 
After  this  there  is  no  further  danger  of  periadenitis. 

"  When  several  glands  are  involved,  a  puncture  should  be  made  in  each. 
For  a  single  yland,  one  puncture  and  one  stirring  up  with  the  sound  is 


412  THE    SIMPLE    AND    THE    VIRULENT    BUBO. 

■usually  sufficient.  Should,  however,  a  repetition  of  the  operation  appear 
necessary,  there  can  be  no  objection  to  it. 

"  In  case  the  point  of  pnncture  has  not  closed,  pus  continues  to  be  dis- 
charged through  the  opening.  The  edges  of  the  glandular  capsule  gradu- 
ally become  adherent  to  the  external  skin  without  the  occurrence  of 
periadenitis,  and  finally  the  cavity  of  the  abscess  closes  by  the  contraction 
of  its  walls  and  by  granulation.  Occasionally  ulceration  of  the  {)uncture 
takes  place,  but  this  is  confined  to  the  skin  and  does  not  extend  in  depth." 

In  case  more  or  less  matter  has  formisd  in  a  bubo  before  the  surgeon  has 
an  opportunity  to  interfere,  two  methods  for  its  evacuation  are  at  his  dis- 
posal, either  by  the  knife  or  by  caustic.  The  former  is,  with  rare  exceptions, 
to  be  preferred  ;  and,  in  our  opinion,  a  free  opening  is  better  than  a  number 
of  small  [lunctures. 

Tiie  hair  should  first  be  shaved  off  from  the  surface  to  facilitate  the 
after-dressing  and  promote  cleanliness.  The  longest  diameter  of  the  ab- 
scess is  in  most  cases  parallel  to  the  inguinal  fold,  yet  if  the  incision  be 
made  solely  in  this  direction,  its  edges  are  approximated  whenever  the 
thigh  is  in  a  flexed  position  and  healing  from  the  bottom  of  the  cavity  is 
interfered  with.  It  is  therefore  desirable  to  secure  one  incision  at  least 
jiarallcl  with  tiie  median  line  of  the  body  and  to  cut  on  either  side  as  cir- 
cumstiinces  may  require,  making  in  the  end  a  crucial  opening.  Any  fis- 
tulous tracks  which  may  exist  at  the  time,  or  which  may  subsequently 
form,  should  be  fully  laid  open,  as  soon  as  discovered.  It  is  often  desira- 
Ide  to  pare  off  a  portion  of  the  skin  fi'om  the  flaps.  This  is  absolutely 
called  for  when  they  are  so  thinned  and  purplish  in  color  that  their  fur- 
ther vitality  cannot  be  expected.  But  in  the  absence  of  such  marked 
s)^mptoms  of  degeneration,  experience  shows  that  the  removal  of  a  por' 
tion  of  the  integument  favors  the  healing  of  a  bubo  which  has  extensively 
suppurated,  without  adding  to  the  subsequent  cicatrix. 

On  o[)ening  a  bubo,  especially  in  strumous  subjects,  we  often  find  that 
we  have  merely  penetrated  into  an  abscess  of  the  cellular  tissue,  within 
whose  cavity  lie  one  or  more  disorganized  glands,  infiltrated  with  pus  and 
almost  isolated  from  their  surrounding  connection.  Now,  it  is  absurd  to 
look  for  healing  of  the  bubo  until  these  glands  are  got  rid  of  by  the  slow 
process  of  ulceration  or  are  removed  by  a  quicker  process.  The  latter  is 
best  accomplished,  the  patient  being  anaesthetized,  by  tearing  them  out 
with  the  fingers  or  scraping  them  out  with  a  Wolkmann's  spoon;  or,  again, 
when  they  are  large  and  sessile  they  may  be  tied  off  by  means  of  a  double 
ligature  passed  through  their  base. 

The  hemorrhage  from  this  operation  is  seldom  so  severe  that  it  may  not 
be  arrested  hy  exposure  to  the  air,  by  ice,  or  pressure  ;  but  should  it  be 
profuse,  or  continued  even  in  a  small  quantity,  the  bleeding  vessel  must  be 
secured.  Carbolized  lint  or  cotton  is  now  introduced  into  every  recess  of 
the  cavity,  paying  particular  attention  to  any  short  sinuses  which  it  was 
not  thought  necessary  to  lay  open  with  the  knife,  and  the  whole  may  be 
covered  with  a  water  dressing.  Care  should  subsequently  be  taken  to 
keep  the  wound  clean  and  avoid  the  collection  and  stagnation  of  matter  by 


TREATMENT    OF    BUBOES.  413 

daily  syringing  or  a  sitz-bath.  If  the  bubo  be  a  virulent  one  and  its  sur- 
face chancroidal,  the  same  local  applications  are  indicated  as  those  men- 
tioned when  speaking  of  the  chancroid. 

In  private  practice  it  will  rarely  be  desirable  to  open  a  bubo  either  by 
incision  or  puncture  otherwise  than  in  one  of  the  methods  above  mentioned. 
3Iany  other  plans,  however,  have  been  advocated,  but  we  regard  most  of 
them  as  unwortliy  of  more  than  mere  mention,  and  some  of  them  not  even 
of  that. 

Perhaps  the  one  most  deserving  of  notice  consists  of  multiple  punctures 
in  buboes  which  have  extensively  suppurated,  in  which  the  skin  over  them 
has  been  undermined  to  a  very  considerable  extent,  and  in  which  a  single 
large  incision,  freely  exposing  the  cavity  of  the  abscess  to  the  air,  may  be 
regarded  as  injudicious.  In  such  cases,  multiple  incisions,  recommended 
by  Vidal,  Langston  Parker,  and  others,  may  be  resorted  to  with  the  idea 
of  evacuating  the  collection  of  matter,  and  securing  by  rest  and  pressure 
a  contraction  of  the  walls  of  the  tumor,  while  still  holding  in  reserve  a 
free  incision  in  case  it  should  be  required. 

Langston  Parker's  favorite  method  was  as  follows  :  "  When  a  bubo  is 
ready  to  be  opened,  we  should  not  suffer  the  skin  to  become  too  thin,  but 
make  several  very  small  punctures  over  its  thinnest  part  with  a  grooved 
needle,  perhaps  six,  eight,  or  ten  ;  through  these  the  matter  will  ooze  out 
till  the  cavity  of  the  abscess  is  empty.  Through  one  of  the  punctures  the 
point  of  a  very  small  glass  syringe  may  be  introduced,  and  a  very  weak 
solution  of  the  sulphate  of  zinc  injected,  in  the  proportion  of  two  or  three 
gi'ains  to  the  half-pint  of  water.  When  the  abscess  is  quite  empty,  place 
over  it  a  large  compress  of  lint,  and  use  moderately  tight  pressure  by 
means  of  a  roller.  In  many  instances,  if  we  can  keep  the  patient  quiet 
for  twenty-four  hours,  we  get  either  partial  or  total  adhesion  of  the  sides 
of  the  bubo,  and  a  speedy  cure  will  be  the  result;  in  other  instances  this 
may  not  be  the  case,  but  by  the  daily  use  of  the  injection  through  one  of 
the  punctures,  which  should  be  kept  open  for  that  purpose,  we  succeed  in 
a  few  days,  in  almost  every  case,  in  effecting  a  cure."  Judging  from  my 
own  experience,  I  am  confident  in  stating  that  this  result  is  overestimated, 
although  the  metliod  of  multii)le  punctures  has  recently  received  the  high- 
est praise  from  no  less  an  authority  than  Zeissl,^  who  speaks  of  it  as  "  a 
triumph  of  conservative  surgery."  Is  it  not  probable  that  Lister's  anti- 
septic method  would  avoid  all  dangers,  real  or  supposed,  of  free  incisions  ? 
Such  has  not  yet  been  tried,  so  far  as  I  know. 

The  following  methods  are  not  to  be  recommended  : — 

Aspiration  of  the  contents  of  the  abscess  (Griinfeld). 

A  filiform  seton  recommended  by  Bonnafont,  by  Mr.  Parker,  also  by 
Dr.  lliimmond  (op.  cit.  p.  oG),  and  reported  against  by  a  committee  of 
the  Soc.  de  Med.  de  Paris,  in  18.09. 

Caustics  have  been  employed  for  the  opening  of  buboes,  particularly 
such  as  are  of  large  size  and  with  the  skin  over  them  much  thinned,  but 

'  Op.  cit.,  vol.  i,  p.  235. 


414  THE    SIMPLE    AND    THE    VIRULENT    BUBO. 

they  are  painful  in  tlieir  applieation  and  without  any  special  advantage. 
Any  i)o\veit'ul  canst ics,  as  Vienna  jjaste,  may  be  used  for  tliis  purpose.  A 
method  proposed  by  MM.  Malajjert'  and  Reynaud^  was  at  one  time  in 
vogue,  but  has  fallen  into  disuse.  It  consisted  in  the  application  of  a 
blister  over  the  tumor,  and  of  a  pledget  of  lint  soaked  in  a  solution  of  cor- 
rosive sublimate  (gr.  xv.  to  5j  of  water)  to  the  vesicated  surface  previously 
freed  from  all  secretion  of  serum.  The  caustic  was  allowed  to  remain  for 
two  hours,  or  until  a  superficial  eschar  was  formed,  when  a  large  poultice 
was  applied.  The  authors  of  this  method  claimed  that,  as  the  eschar  was 
detached,  the  contents  of  the  abscess  oozed  out  through  minute  openings 
in  the  integument,  the  whole  substance  of  which  v.as  not  destroyed,  and 
that  the  walls  of  the  cavity  were  so  stimulated  and  moditied  by  the  caustic 
that  they  rapidly  contracted  and  adhered.  As  stated  upon  a  previous 
page,  this  method,  although  designed  by  its  authors  solely  for  the  treat- 
ment of  buboes  after  suppuration  has  taken  place,  has  been  ap[)lied  by 
others  for  the  purpose  of  effecting  resolution.  The  excessive  pain  attend- 
ing the  application  is  not  counterbalanced  by  any  advantage  over  milder 
methods. 

Gangrene  attacking  a  bubo  must  be  met  by  the  same  means  as  those 
already  mentioned  when  speaking  of  the  gangrenous  chancroid.  Con- 
tinuous immersion  in  a  bath,  described  upon  page  388,  is  a  most  valu- 
able mode  of  treatment  which  has  been  found  successful  in  many  cases 
whefe  other  means  had  failed,  and  it  relieves  the  patient  from  the  exces- 
sive pain  which  often  attends  the  change  of  dressings.  Attention  to  the 
general  condition  of  the  patient;  the  administration  of  tonics,  cod-liver 
oil,  and  of  opium,  when  indicated ;  the  local  application  of  iodoform  and, 
in  obstinate  cases,  of  the  more  powerful  caustics,  as  the  carbo-sulphuri3 
paste  or  the  actual  cautery,  should  not  be  forgotten. 

Zeissl  advises,  on  the  first  appearance  of  any  symptoms  of  gangrene, 
filling  the  cavity  of  the  bubo  alternately  with  lint  soaked  in  a  solution  of 
chloride  of  lime  and  with  "  gypstheer"  (one  part  of  coal  tar  and  twenty 
parts  of  gypsum),  and  covering  it  with  ice-cold  compresses.  He  says  that 
the  extent  of  the  gangrene  can  sometimes  be  limited  by  the  use  of  "  cam- 
pherschleim"  (one  drachm  of  camphor  to  an  ounce  and  a  half  of  mucilage). 

Any  sinuses  which  form,  as  they  may  do  either  below  or  above  Poupart's 
ligament,  terminating  in  counter  openings  a  long  way  off,  must  be  treated 
according  to  the  principles  of  general  surgery,  keeping  in  view  the  general 
condition  of  the  patient  and  his  consequent  ability  to  withstand  a  cuttirg 
operation,  and  also  the  course  of  the  sinus,  its  proximity  to  important 
vessels,  etc.  In  some  cases  free  incision  may  be  resorted  to ;  in  others, 
we  must  content  ourselves  with  a  ligature  passed  through  the  fistula  and 
gradually  tightened,  or  with  injections  into  the  passage  followed  by  care- 
fully adjusted  pressure  over  its  track.  I  have  little  faith  in  drainage-tubes, 
which  have  also  been  employed. 

'  Arch.  gen.  de  m6d.,  Paris,  Mars,  1832. 
'  Traite  d.  mal.  v6n.,  p.  70, 


TREATMENT    OF    BUBOES.  415 

In  the  hemorrhagic  bubo,  the  indications  for  the  general  treatment  of 
the  patient  are  evident.  As  to  local  applications.  Prof.  Gambeiini  is  in 
the  habit  of  using  the  liquor  ferri  perchloridi,  or  he  sometimes  sprinkles  a 
thin  layer  of  caustic  potash  in  powder  over  the  surface,  so  as  to  form  an 
eschar.  A  light  touch  with  a  red-hot  iron  may  be  useful.  The  cavity 
should  be  thoroughly  exposed  by  free  incisions,  the  impaired  integument 
be  pared  otf,  and  the  glands  removed  by  enucleation,  ligation,  or  cauteriza- 
tion in  severe  cases. 


416  LYMPHITIS 


CHAPTER    VI. 
LYMPH  ITIS. 

Having  described  the  inflammation  of  the  ganglia  wliich  constitutes  a 
bubo,  it  will  be  necessary  to  devote  but  a  few  words  to  the  consideration 
of  lynipliitis,  since  the  phenomena  are  almost  identical  in  the  two  cases  ; 
the  hitter  being  in  fact  a  bubo  seated  in  tlie  course  of  a  lymphatic  vessel 
instead  of  in  the  terminal  ganglion. 

As  with  buboes,  so  with  lymphitis,  we  find  two  forms  : — 

I.  Simple  Ly^iphitis. 
II.  Virulent  Lymphitis. 

Simple   Lymphitis Simple  lymphitis  may  be  due  to  any  of  the 

causes  already  mentioned  as  producing  a  simple  bubo.  A  hard,  uneven 
cord  is  observed  running  along  the  dorsum  of  the  penis  towards  the  mons 
veneris,  in  which  it  is  usually  lost.  This  cord  is  made  up  in  part  of  the 
thickened  and  distended  walls  of  the  lymphatic  vessels,  but  in  part  also  of 
the  infiltrated  cellular  tissue  in  its  neighborhood.  The  dorsal  vein  and 
artery  are  usually  included  in  the  inflammatory  engorgement  and  cannot 
be  isolated  from  the  vessel.  There  is  often  more  or  less  oedema  of  the 
cellular  tissue,  especially  of  the  prepuce.  Considerable  heat  and  pain  are 
experienced,  and  the  course  of  the  inflamed  vessel  is  marked  by  a  red  line 
upon  the  surface.  As  we  shall  see  hereafter,  these  symptoms  of  acute 
iiiflamuiMtion  are  sufficient  to  distinguish  lymphitis  from  the  induration  of 
the  lymphatics  which  often  accom[)anies  a  chancre. 

This  form  of  lymphitis  is  capable  of  resolution,  Avhich,  indeed,  is  its 
most  frequent  termination.  If  sujtpuration  occurs,  the  pus  is  not  inocu- 
lable. 

ViitrLENT  Lymphitis — As  a  general  rule,  morbid  products  which 
undergo  absorption  do  not  manifest  their  presence  in  the  lymphatics  them- 
selves, probably  in  consequence  of  the  raj)idity  of  their  passage ;  and  the 
changes  wliicii  take  place  in  the  ganglia  where  their  progress  is  impeded 
are  tiie  oidy  indication  that  this  system  of  vessels  is  affected.  In  con- 
formity with  this  law,  the  lymphatics  which  convey  the  pus  from  a  chan- 
croid in  the  direction  of  the  ganglion  generally  escape,  but  in  some 
instances  inoculation  takes  place  at  one  or  more  points  in  the  course  of 
tlie  vessel,  pn)})ably  at  the  site  of  its  valves,  and  virulent  lymphitis  is  set 
up,  the  early  symptoms  of  which  are  the  same  as  those  of  the  simple 
form.     Supi)uration,  however,  is  inevitable,  and  when  the  abscess  is  opened 


LYMPHITIS.  4n 

ti  chancroid  is  the  resuh,  as  in  the  case  of  a  virulent  bubo.  Several  of 
these  virulent  ulcers  sometimes  occupy  the  sides  or  dorsum  of  the  penis, 
following  the  course  of  the  lymphatic  vessels,  and  communicate  with  each 
other  beneath  the  integument  by  means  of  minute  fistulous  tracks,  which 
may  be  penetrated  by  a  tine  probe. 

This  affection  of  the  lymphatics  is  seldom  met  with  in  women,  in  whom, 
however,  it  occurs  in  rare  instances  in  the  labia  majora. 

The  complications  and  the  treatment  are  the  same  as  those  of  the  virulent 
bubo,  although  destructive  cauterization  is  less  frequently  applicable, 
partly  on  account  of  the  situation  of  the  sore,  but  chiefly  from  the  extreme 
probability  that  reinoculation  will  take  place  on  the  fall  of  the  eschar  ;  we 
must,  therefore  be  content  in  most  cases  with  dressings  of  iodoform,  a  solu- 
tion of  carbolic  acid,  aromatic  wine,  etc. 


27 


PART  III. 
SYPHILIS. 


CHAPTER  I. 

INTRODUCTORY  REMARKS. 

Syphilis  is  one  of  the  class  of  diseases  called  "  infectious,"  the  char- 
acteristics of  which  ai'e  the  following  : — 

1.  The  presence  of  a  morbid  poison  or  virus,  which  transmits  the  dis- 
ease from  one  individual  to  another. 

2.  The  immunity  which  one  attack  generally  confers  against  a  second. 

3.  A  "  period  of  incubation,"  during  which  the  virus  is  latent  and  gives 
no  external  manifestation  of  its  presence  in  the  system. 

4.  A  degree  of  order  and  regularity  in  the  evolution  of  the  symptoms. 
There  are  two  forms  of  syphilis,  the  acquired  and  the  hereditary.     Both 

are  the  result  of  the  same  morbid  influence  or  virus,  but  their  course, 
lesions,  and  symptoms  vary  in  so  many  particulars  that  they  require  a 
separate  description. 

Acquired  syphilis  is  the  disease  communicated  bj'  an  infected  person  to 
one  free  from  sypliilis,  and  always  manifests  itself  first  at  the  point  of 
inoculation,  by  an  initial  lesion  or  chancre.  Acquired  syphilis  without  a 
chancre,  or,  as  some  French  writers  have  called  it,  "  syphilis  d'emblee," 
is  a  myth. 

Hereditary  syphilis  is  syphilis  inherited  from  either  parent,  infection  of 
the  ovum  having  taken  place  at  the  time  of  conception.  In  this  form  of 
syphilis,  the  initial  lesion  or  chancre  is  wanting. 

Syphilitic  Virus. 

The  existence  of  a  syphilitic  virus  has  sometimes  been  called  in  ques- 
tion,* but  at  the  present  day  is  established  beyond  a  doubt.  The  daily 
experience  of  every  surgeon  demonstrates  that  in  syphilis  there  exists  a 

'  Cliiefly  by  the  following  authors  :  Biiv,  Mdthode  nouvelle  de  trailer  les  mala- 
dies ven<5riemies  par  les  gateaux  toniques  mercuriels,  t.  i,  chap.  3,  p.  4.'),  Paris, 
1789;  Caron,  Nouvelle  doctrine  des  maladies  ven^riennes,  Paris,  1811,  p.  33; 
Riciioxi)  DES  Bkus,  De  la  non-existence  du  virus  vdnerien,  Paris,  182G,  t.  i,  p. 
67;  JouKDA.x,  Traite  complet  des  maladies  vencriennes,  t.  i,  p.  888. 


420  SYPHILIS. 

contagious  element,  by  means  of  which  the  disease  is  communicated  ;  and 
thou'fh  this  morbid  poison  has  nevex*  been  detected  by  the  senses,  the 
microscope,  or  chemical  analysis,  its  presence  is  fully  proved  by  its  effects. 
Various  theories  have  been  offered  to  explain  its  nature,  but  they  have  all 
been  either  fanciful  or  untenable,  and  their  authors  have  almost  invariably 
confounded  the  syphilitic  with  the  chancroidal  virus.  Thus  the  essential 
element  of  this  disease  has  always  remained  concealed,  and  probably  will 
so  remain,  until  our  knowledge  in  general  of  the  principle  of  life  and  the 
nature  of  disease  is  very  much  greater  than  now. 

The  severity  of  the  symptoms  produced  by  syphilis  on  its  first  appear- 
ance in  the  latter  part  of  the  fifteenth  century,  compared  with  its  greater 
benignity  at  the  present  day,  afibrds  some  ground  for  believing  that  its 
virus  is  slowly  but  gradually  losing  in  intensity  in  the  same  manner  as 
the  vaccine  virus  becomes  weaker  after  many  successive  removes  from  the 
cow.  This  fact  was  noticed  by  Astruc^  in  the  middle  of  the  last  century, 
who  says  :  "  Whatever  might  formerly  be  the  power  and  efficacy  of  the 
venereal  disease  when  it  was  new  and  in  vigor,  while  the  undivided  poison 
violently  effervesced,  there  is  nothing  like  it,  I  imagine,  to  be  feared  from 
it  now,  as  it  is  weakened,  become  old,  and  its  force  almost  quite  spent." 
Another  explanation  advanced  by  some  writers  is,  that  the  syphilitic  virus 
retains  its  power,  but  that  a  preservative  influence  is  transmitted  to  pos- 
terity by  those  who  have  the  disease,  which,  like  some  vegetables,  gradu- 
ally exhausts  the  soil  from  which  it  springs  of  the  materials  necessary  to 
its  support.  Admitting  the  fact,  the  first  mentioned  theory  is  probably 
tlie  correct  one. 

Syphilis  cojimonly  Occurs  but  Oxce  in  the  same  Person. 

It  is  true  of  all  diseases  which  are  botli  contagious  and  constitutional, 
that  a  person  who  has  once  had  them  is  iiidisposed  to  contract  them  again. 
Smallpox,  scarlet  fever,  measles,  the  hooping-cough,  and  the  vaccine  disease, 
all  follow  this  law  ;  and  in  the  rare  exceptions  which  sometimes  occur,  the 
symptoms  are  generally  so  modified  as  still  to  evince  the  protecting  influ- 
ence of  the  first  attack.  The  applicability  of  this  law  to  syphilis  was  first 
announced  by  Ricord  in  1839,  and  in  spite  of  frequent  denials,  may  now 
be  regarded  as  unquestionable.  The  immunity  confierred  by  an  attack  of 
syphilis  is  as  great  as  that  resulting  from  an  attack  of  any  of  the  other  in- 
fectious diseases  just  mentioned. 

Witliout  due  care,  however,  it  is  an  easy  matter  to  be  deceived  on  this 
point.  After  syphilitic  infection,  but  few  persons  escape  with  only  one 
outbreak  of  general  lesions ;  however  thorough  their  treatment  may  have 
been,  one  or  more  relapses  usually  occur,  and  if  one  of  these  has  been  pre- 
ceded by  a  newly  cauglit  venereal  ulcer,  the  secondary  symptoms  wiiich 
follow  are  frequently  ascribed  to  its  influence,  especially  if  the  ulcer  hap- 
pene<l  to  be  situated  upon  the  remaining  induration  of  the  first,  and  thus 

'  Englisli  translation  of  Astruc,  London,  1754,  p.  102, 


INTRODUCTORY    REMARKS.  421 

simulated  a  chancre.  Fortunately,  we  are  able  in  most  instances  to  recog- 
nize a  recent  attack  of  syphilis  by  the  following  signs,  and  in  their  absence 
to  ascribe  the  lesions  to  an  old  infection  : — 

1.  By  the  induration  of  the  preceding  chancre  and  neighboring  lymphatic 
ganglia. 

2.  By  the  time  elapsing  between  the  appearance  of  the  suspicious  ulcer 
and  that  of  the  general  symptoms ;  the  interval,  in  the  absence  of  treat- 
ment, and  when  the  latter  are  dependent  upon  tl«e  same  infection  as  the 
former,  being  very  uniformly  about  six  weeks,  and  rarely  exceeding  three 
months. 

3.  By  the  character  of  the  lesions,  whether  belonging  to  an  early  or  late 
stage  of  syphilis. 

4.  In  some  cases,  by  the  influence  of  treatment ;  the  early  lesions  of 
general  syphilis  yielding  most  readily  to  mercury ;  the  later  to  iodide  of 
potassium. 

But  are  there  no  exceptions  to  the  law  of  the  "  unicity  of  syphilis," 
such  as  undoubtedly  exist  in  respect  to  other  infectious  diseases  ?  Numer- 
ous instances  are  recorded  in  which  smallpox,  scarlet  fever,  the  measles, 
and  liooping-cough  have  occurred  twice  in  the  same  person.  A  single 
vaccination  does  not  always  protect  one  through  life  from  variola.  A 
second  inoculation  with  the  vaccine  virus  performed  in  adult  life  will  often 
succeed  nearly  if  not  quite  as  well  as  the  first  vaccination  performed  in 
childhood.  In  the  case  of  a  second  infection  from  any  of  the  diseases  men- 
tioned, the  severity  of  the  attack  will,  as  a  general  but  not  an  invariable  rule, 
be  in  inverse  ratio  to  the  lengtli  of  time  which  has  elapsed  since  the  pre- 
vious infection.  In  other  words,  the  protecting  influence  of  the  virus 
appears  to  gradually  diminish  and  finally  disappear.  One  attack  confers 
complete  immunity  for  a  time  ;  then  comes  a  period  in  which  inoculation 
(as  of  the  variolous  or  vaccine  poisons)  will  produce  a  local  eflfect  without 
general  reaction,  and  finally  a  third  period  in  which  constitutional  manifes- 
tations of  greater  or  less  intensity  are  possible. 

As  early  as  184.5,  Ricord  himself  expressed  the  belief  that  similar  excep- 
tions to  the  law  of  the  unicity  of  syphilis  would  also  be  found  to  exist;  he 
trusted  it  was  so,  since  it  would  prove  the  efi^ect  of  syphilis  was  not  neces- 
sarily life-long  ;  at  the  same  time  he  confessed  he  had  never  as  yet  met 
with  an  unquestionable  instance. 

Since  tlien  attention  has  been  directed  anew  to  this  subject.  Quite  a 
number  of  cases  of  repeated  syphilitic  infection  in  the  same  person  have 
been  reported  by  various  observers,  and  Ricord  himself  has  met  with  two 
which  he  regards  as  conclusive.  A  valuable  contribution  to  our  knowl- 
edge of  syphilitic  reinfection  has  appeared  from  tlie  pen  of  Diday,'  who 
believes  that  he  has  met  with  over  twenty  cases  (?).  The  conclusions  at 
which  he  has  arrived  are  tlie  following: — 

1.    As  a  general  rule,  the  syi)hilitic,  like  other  kinds  of  virus,  does 

'  De  la  reinfection  syphilitique,  de  ses  degr^s  et  de  ses  modes  ilivers,  Arch.  gdn. 
de  m6d.,  juilletet  aoiit,  1803. 


422  SYPHILIS. 

not  exercise    the   same  action    twice    in   succession    upon   the  same   in- 
dividual. 

2.  AVhen  applied  (under  such  conditions  as  to  permit  absorption)  to  a 
syphilitic  subject,  this  virus  produces  no  effect ;  applied  to  a  subject  who 
has  had,  but  who  no  longer  has  syphilis,  it  produces  a  modified  form  of 
syphilis. 

3.  Tlie  more  feeble  the  first  attack,  and  the  longer  the  time  that  has 
since  elapsed,  the  more  energetic  will  be  the  action  of  the  virus  and  the 
more  severe  will  be  the  second  attack  of  syphilis ;  and  vice  versa. 

4.  Exjjerience  shows  that  the  only  persons  upon  whom  a  second  intro- 
duction of  the  syphilitic  virus  produces  a  pathological  effect  are  those 
who  are  cured  of  their  first  attack,  or  who  at  least  have  no  other  symptoms 
than  those  which  cannot  be  transmitted  either  by  generation  or  by  contact 
(tertiary  lesions). 

o.  The  effects  of  the  second  introduction  of  the  virus,  under  the  condi- 
tions just  mentioned,  have  presented  in  twenty-five  cases  which  have  been 
observed,  the  following  varieties  : — 

A.  In  fourteen,  there  has  been  an  ulcer  presenting  all  the  characteristics 
of  an  indurated  chancre,  except  concomitant  induration  of  the  ganglia., 
and  this  ulcer  has  not  been  followed  by  general  symptoms.  Thus  the 
absence  of  glandular  induration  may  enable  the  surgeon  to  recognize 
in  advance  those  indurated  chancres  which  will  not  be  followed  by  genei-al 
lesions. 

B.  In  nine  cases,  there  was  an  indurated  chancre  followed  by  general 
symptoms,  which  were  less  intense  than  those  of  the  first  attack. 

C.  In  two  cases,  there  was  an  indurated  chancre  followed  by  general 
symptoms  of  greater  intensity  than  in  the  first  attack. 

G.  If  we  compare  the  intervals  of  time  elapsing  between  the  two  attacks 
in  these  different  series  of  cases,  we  find  that  the  shorter  the.  interval  the 
more  feeble  was  the  effect  of  the  second  infection  ;  the  interval  being  at  a 
minimum  when  the  second  attack  produced  only  a  cliancre,  and  at  a 
maximum  when  the  general  symptoms  of  the  second  attack  were  more  in- 
tense than  those  of  the  first. 

It  is  asserted  by  Diday  tliat  the  twenty  cases  above  referred  to  were  ob- 
served by  him  in  his  private  ])ractice  within  a  {)eriod  of  six  years,  and  he 
therefore  infers  that  instances  of  syphilitic  reinoculation  are  more  frequent 
than  has  generally  been  admitted,  although  they  are  rare  when  com- 
pared with  the  whole  number  of  cases  of  syphilis  that  occur.  This  sur- 
geon draws  the  following  conclusions  from  a  consideration  of  this 
subject : — 

The  reinfection  of  a  man  who  has  had  syphilis  proves  that  he  was  cured 
of  it  at  the  time  of  the  second  infection. 

The  possibility  of  reinfection  proves  that  syphilis  can  be  radically 
cured — a  fact  denied  by  many  authors,  who  admit  only  a  cure  of  syphilitic 
manifestations,  and  who  maintain  tliat  the  constitutional  poisoning  (or 
diathesis,  as  they  erroneously  call  syphilitic  intoxication)  is  perpetual. 

Tlie  average  time  necessary  for  a  radical  cure  may  be  deduced  from 


INTRODUCTORY    REMARKS.  423 

the  cases  above  referred  to,  and  which  give  a  minimum  of  twenty-two 
months. 

In  any  case  of  reinfection  from  sypliilis,  the  surgeon  sliould  always  wait 
for  general  lesions  to  appear  before  giving  mercury,  since  in  the  majority 
of  cases  the  effect  is  limited  to  the  production  of  a  chancre,  and  specific 
treatment  is  not  required. 

Since  the  publication  of  Diday's  paper  numerous  autliors  have  reported 
cases  of  syphilitic  reinfection,  to  the  number  in  all  of  above  sixty  ;  but 
fully  one-half  of  these  are  not  instances  of  a  second  attack  of  syphilis  at 
all.  The  error  several  authors  have  fJxUen  into  is  in  regarding  relapsing 
indurations  as  primary  chancres.  They  thus  mistake  a  manifestation  of 
an  old  contagion  as  an  evidence  of  a  new  one.  Before  we  can  admit  a 
second  attack  of  syphilis,  we  must  have  an  undisputed  history  of  the  first 
infection  :  we  must  have  proof  beyond  doubt  of  a  second  chancre,  which  is 
followed  by  well-marked  enlargement  of  the  inguinal  ganglia,  and  later  on 
hy  secondary  manifestations  of  an  imdoubtedly  syphilitic  nature.  Without 
this  succession  of  lesions  similiar  to  tliose  of  the  first  attack,  we  cannot 
admit  the  claims  of  any  case  of  syphilitic  reinfection. 

Syphilis  Possesses  a  Period  of  Incubation. 

By  a  period  of  incubation  we  understand  the  lapse  of  time  following 
the  introduction  of  a  morbid  poison  into  the  system,  and  preceding  the 
earliest  manifestation  of  its  presence.  Thus  a  person  is  exposed  to  small- 
pox, the  measles,  or  scarlatina,  and,  when  contagion  takes  place,  breaks 
out  with  the  symptoms  of  the  disease  only  after  an  interval,  which,  with 
slight  variation,  is  constant  in  each  of  tlie  affections  mentioned,  and  during 
which  he  enjoys  his  usual  state  of  health.  That,  in  the  case  of  syphilis, 
such  a  period  elapses  between  the  act  of  contagion  and  the  asppearance  of 
its  initial  lesion,  will  be  shown  in  the  next  chapter.  But  syphilis  also  has 
a  second  period  of  incubation,  between  the  appearance  of  the  chancre  and 
the  development  of  its  general  manifestations,  and  of  this  we  shall  speak 
presently. 

The  Order  of  Evolution  of  Syphilitic  Symptoms,  and  the 
Classification  Founded  Thereon. 

The  classification  of  syphilitic  manifestations  in  common  use  is  founded 
chiefly  u{)on  tlie  order  of  their  evolution,  and  embraces  " primary,"  "second- 
ary," and  "•  tertiary  symptoms."  I'rimary  symptoms  should  include  the 
initial  lesion  which  appears  at  the  point  where  the  virus  enters  the  economy, 
and  the  induration  of  tlie  neighboring  lymphatic  ganglia.  Next  follows, 
after  ft  period  of  incubation,  another  set  of  symptoms,  called  "  general," 
because  they  are  developed  at  points  distant  from  the  seat  of  the  initial 
lesion,  to  which  they  stand  in  no  necessary  anatomical  relation. 

Ricord's  classification  of  general  symptoms  into  secondary  and  tertiary^ 
which  is  generally  adopted  at  the  jjresent  day,  is  founded  upon  Hunter's 
division  of  the  tissues  affected  by  syphilis  into  "parts  first  in  order,  and 


424  SYPHILIS. 

parts  second  in  order."  Both  systems  are  based  upon  the  conformity  of 
nature  to  laws  which  are  more  or  less  fixed  as  well  in  disease  as  in  health, 
and  upon  the  anatomical  structure  of  the  parts  affected.  An  important 
distinction,  also,  which  Ricord  claims  to  exist  between  the  two  divisions 
in  this  classification,  is  a  difference  in  the  effect  of  remedies;  secondary 
symptoms  being  more  susceptible  to  mercury,  and  tertiary  to  iodine  and 
its  compounds. 

Kicord's  classification  may  best  be  given  in  his  own  words  ;  "  Secondary 
sym[)tonis  are  the  consequence  of  the  absorption  of  the  virus,  and  are 
transmissible  by  hereditary  descent,  without  being  inoculable.  Tertiary 
symptoms  are  not  only  not  inoculable,  but  cannot  be  transmitted  by 
hereditary  descent  under  their  peculiar  type,  although  in  consequence  of  a 
kind  of  degeneration  or  modification  of  the  syphilitic  virus,  they  are  pro- 
bably one  of  the  most  fruitful  sources  of  scrofula. 

"  Secondary  symptoms  rarely  occur  before  the  third  week  following  the 
appearance  of  primary  symptoms,  and  more  rarely  still  after  the  sixth 
month  ;  whilst  tertiary  symptoms  scarcely  ever  appear  before  the  sixth 
month,  and  may  not  until  after  several  yeai'S. 

"To  secondary  symptoms  are  referred  certain  affections  of  the  skin 
(syphilitic  eruptions)  and  of  some  parts  of  the  mucous  membranes 
(mucous  patches,  condylomata,  and  superficial  ulcerations)  and  their 
dependencies  (alopecia  and  onyxis)  ;  also  some  peculiar  pathological  affec- 
tions of  the  eyes  (iritis),  lym[)hatic  ganglia  (engorgement  of  the  glands  in 
various  parts  of  the  body,  especially  the  neck),  etc.  Tertiary  symptoms 
consist  of  certain  changes  which  take  place  in  the  subcutaneous  or  sub- 
mucous cellular  tissue  (gummy  tumors),  in  the  testicles  (orchitis),  in  the 
filjrous  and  osseous  tissues  (periostitis,  ostitis,  caries,  etc.),  and  in  the 
deeper  organs. 

"Proper  treatment  of  the  primary  symptom  may  prevent  the  develop- 
ment of  secondary  symptoms.  Very  often  this  treatment  cures  the  pri- 
mary and  arrests  only  the  secondary  symptoms ;  in  this  Avay  may  be 
explained,  for  examj>le,  the  late  appearance  of  diseases  of  the  periosteum 
and  bones,  without  the  secondary  link,  in  persons  who  have  taken  mercury. 
When  once  the  primary  ulcer  is  healed,  it  cannot  be  reproduced  except  by 
a  new  contagion  ;  while  secondaiy  and  tertiary  symptoms  may  appear 
repeatedly,  and  at  various  intervals,  within  periods  which  cannot  be 
limited.  An  apparent  inversion  in  the  succession  of  secondary  and  tertiary 
symptoms  is  observed  only  in  persons  who  have  undergone  treatment. 
After  the  appearance  of  constitutional  symptoms,  the  syphilitic  diathesis 
may  cease  spontaneously  or  in  consequence  of  appropriate  treatment,  and 
yet  the  symptoms  persist  under  the  influence  of  purely  local  causes,  as  is 
observed  especially  in  many  cases  of  diseased  bones. "^ 

In  another  place  Ricord  says  of  tertiary  symptoms:  "They  not  only 
differ  from  primary  and  secondary  symptoms  in  affecting  the  deeper  tissues, 
but  also  in  the  fact  that  in  tliem  syphilis  loses,  in  part,  its  peculiar  type. 
Tiiough  the   skin  is  often  affected   at  this  period   with  the  most  severe 

•  Notes  to  Hunter,  p.  396. 


INTRODUCTORY    REMARKS.  425 

tubercular  eruptions,  yet  the  subcutaneous  and  submucous  cellular  tissues, 
and  the  fibrous  and  osseous  systems  are  far  more  frequently  involved. 
But,  in  addition  to  these  parts,  where  the  tardy  effects  of  constitutional 
syphilis  are  so  common  and  clearly  admitted  by  all  good  observers,  we 
may  well  inquire  whether  there  be  any  privileged  tissues  of  the  body 
which  are  invariably  exempt  from  its  effects.  We  would  inquire,  also, 
if  syphilitic  infection,  though  it  may  not  produce  all  the  evils  with  which 
it  is  reproached,  be  not  in  a  multitude  of  cases  the  cause  of  the  evolution, 
or  '  putting  into  action' — to  use  an  expression  of  Hunter's — of  diseases 
which  have  previously  existed  in  a  latent  state,  and  of  which  it  is  thus 
only  the  exciting  cause  ?  Observation  replies  in  the  affirmative  to  these 
questions,  and  also  teaches  us  that  tertiary  symptoms  may  continue  under 
the  influence  of  the  virulent  cause,  or  persist  as  local  effects  after  this 
cause  has  been  destroyed  or  neutralized  by  treatment ;  it  shows,  in  a 
multitude  of  cases,  that  the  syphilitic  virus,  after  having  been  the  cause 
of  other  diseases,  may  cease  to  exist  or  persist  as  a  complication ;  and 
these  are  circumstances  which,  though  real,  are  unfortunately  not  always 
easily  appreciated. 

"Tertiary  symptoms  rarely  occur  before  the  sixth  month  following  the 
appearance  of  the  primary  ulcer,  and  the  latter  seldom  remains  at  the 
time  of  their  development;  but  they  are  frequently  attended  by  some 
secondary  symptom.  They  never  furnish  inoculable  secretions,  nor  trans- 
mit characteristic  constitutional  syphilis  from  parent  to  child ;  their  only 
hereditary  influence  being  the  frequent  transmission  of  a  taint  as  injurious 
and  almost  as  fearful,  viz.,  a  scrofulous  diathesis." 

Ricord's  classification  may,  I  think,  be  resolved  into  two  parts.  The 
first  is  the  chronological  system,  which,  originating  with  Fernel  and 
Hunter,  has  been  freed  from  many  errors  by  Ricord,  and  greatly  perfected 
by  this  surgeon's  keen  powers  of  observation,  and  which  is  both  natural 
and  eminently  ])ractical.  The  second  part  consists  of  various  additions 
relative  to  the  inoculai)ility  of  the  different  orders  of  symptoms,  their  trans- 
mission by  hereditary  descent,  and  the  effect  of  treatment;  some  of  which 
are  open  to  criticism.     I  shall  speak  of  each  in  turn. 

The  general  symptoms  of  syphilis  are  not  drawn  at  hap-hazard,  l)ut  make 
their  appearance  with  a  great  degree  of  order  and  regwlai'ity.  This  fact 
is  most  ap])arent  in  those  lesions  which  follow  immediately  upon  the  period 
of  incubation,  and  which  vary  but  little  in  difllarent  subjects.  Allow  any 
patient  with  a  chancre  to  go  without  treatment,  and  it  may  be  predicted 
with  almost  absolute  certainty,  that  within  three  months  he  or  she  will  be 
attacked  by  the  following  category  of  symptoms  witii  but  little  variation, 
viz.,  general  lassitude,  accompanied  by  headache  and  fleeting  pains  in 
various  parts  of  the  body;  alopecia;  an  eruption  of  blotches  or  papules 
upon  the  skin;  pustules  upon  the  hairy  scalp;  engorgement  of  the  post- 
cervical  glands;  and  whitish  patches,  which  may  become  ulcerated,  upon 
the  mucous  membrane  of  the  mouth,  anus,  or  vulva. 

Subsequent  to  the  first  outbreak  of  general  syphilis,  the  same  uniformity 
does  not  prevail;  and  certain  symptoms  are  absent  in  one  case  and  present 


426  SYPHILIS. 

in  another,  or  they  appear  to  be  modified  by  the  constitution  of  the  patient, 
the  hygienic  conditions  in  which  he  is  placed,  his  habits,  and  especially 
Ity  treatment.  But  if  we  take  a  number  of  cases,  some  of  which  supply 
what  is  wanting  in  others,  we  find  that  we  can,  as  it  were,  make  up  a 
comi)lete  series,  in  which  the  symptoms  progress  by  a  regular  gradation, 
and  may  be  divided  into  two  classes,  distinguishable  by  the  time  of  their 
ajjpearance,  their  character,  and  their  seat.  Those  of  the  first  class  follow 
immediately  upon  the  earliest  general  symptoms  before  mentioned,  with 
which  they  are  evidently  identical  in  character.  Those  of  the  second 
class  never  occur  until  after  a  certain  interval  which  experience  enables 
us  to  determine  with  great  precision.  Again,  the  order  of  the  two  classes 
is  never  i-eversed.  For  instance,  a  patient  who  has  been  suffering  with 
symptoms  belonging  to  the  second,  as  deep  tubercles  of  the  cellular  tissue 
or  caries  of  the  bones,  is  never  known  to  exhibit  the  premonitory  fever, 
exanthematous  eruption,  and  other  early  symptoms  of  the  first.  The 
disease  progresses  with  greater  rapidity  in  some  cases  than  in  others,  yet 
owing  to  the  general  uniformity  referred  to,  simple  inspection  of  a  patient 
will  enable  any  one  familiar  with  its  natural  course  to  arrive  at  an  approxi- 
mate conclusion  as  to  the  length  of  time  that  has  elapsed  since  contagion, 
and  also  as  to  the  character  of  the  preceding  symptoms,  unless  these  have 
been  altogether  suppressed  by  treatment. 

A[)parent  exceptions  to  the  regular  succession  of  the  general  symptoms 
of  syphilis  are  met  with,  and  may  readily  deceive  an  inexperienced  ob- 
server. One  of  the  most  frequent  of  these  is  due  to  treatment.  It  often 
happens  that  a  patient  had  a  chancre  many  years  ago,  and  perhaps  early 
secondary  sym[)toms,  for  one  or  both  of  which  he  took  mercurials;  a  long 
period  has  since  passed  without  further  general  manifestations;  but  his 
system  has  continued  under  the  infiuence  of  syphilis,  wliich  finally  becomes 
active  again  and  gives  rise  to  tertiary  lesions.  Evidently  the  exemption 
from  late  secondai-y  symptoms  may  be  ascribed  to  mercury. 

Again,  the  date  of  the  first  appearance  of  any  lesion  determines  its  posi- 
tion in  the  syphilitic  scale;  while  its  persistency  may  be  due  to  many 
causes,  too  lumierous  to  mention.  It  is  a  very  common  occurrence  for  a 
chancre  to  remain  until  secondary  symptoms  break  out ;  but  we  do  not 
thc^refore  conclude  that  both  belong  to  the  same  order.  In  the  same  way, 
secondary  are  often  present  long  after  tertiary  manifestations  have  super- 
vened. In  Kicord's  admirable  remarks  already  quoted,  allusion  has  been 
made  to  the  fact  that  syphilis  may  give  rise  to  symptoms,  which  are  con- 
tinued by  various  causes  and  especially  by  a  strumous  diathesis,  long  after 
tlie  exciting  cause  has  been  subdued.  Moreover,  many  syphilitic  lesions, 
and  particularly  eruptions  u])on  the  skin  and  mucous  membranes,  may, 
either  with  or  without  treatment,  disappear,  and  again  return  within  a 
limited  period  with  the  same  characters  as  at  first.  This  tendency,  how- 
ever, ceases  with  time ;  and  relapses  after  a  considerable  interval  are  in 
all  cases  rare.  For  instance,  syphilitic  erythema,  whi(!h  usually  appears 
aljout  the  sixth  week  after  the  development  of  the  chancre,  may  perhaps 


INTRODUCTORY    REMARKS,  427 

return  as  late  as  the  eighth  or  ninth  month,  but  never  several  years  after 
the  chancre. 

Finally,  the  same  name  is,  in  several  instances,  applied  to  symptoms 
which  are  in  reality  distinct,  and  which  are  widely  separated  upon  the 
syphilitic  scale.  Thus  there  is  a  form  of  alopecia  which  is  one  of  the 
earliest  general  symptoms,  and  in  which  the  hair  is  freely  shed  from  the 
scalp  and  eyebrows,  but  may  grow  again,  since  the  hair-bulbs  are  not 
seriously  affected;  and  there  is  another  and  rarer  form,  observed  only  in 
the  later  stages  of  syphilis,  in  which  the  whole  integumental  surface 
becomes  permanently  bald.  Two  forms  of  iritis,  ecthyma,  etc.,  are  also 
observed  at  distinct  periods ;  but  these  constitute  no  exception  to  the  law 
of  succession  of  syphilitic  manifestations. 

We  thus  see  that  a  simple  chronological  division  of  constitutional  symp- 
toms may  be  maintained;  but  there  are  several  objections  to  the  additions 
made  to  this  system  by  Eicord,  as  I  shall  proceed  to  show. 

In  the  first  place,  Ricord's  statement  that  "secondary  symptoms  are  not 
capable  of  inoculation,"  is  true  in  the  guarded  sense  in  which  it  was  in- 
tended, viz.,  that  they  are  not  inoculable  upon  persons  bearing  them;  but 
the  inference  which  was  also  designed  to  be  conveyed,  that  they  differ  in 
this  respect  from  a  chancre,  is  not  true,  as  Eicord  himself  has  since 
acknowledged.  Both  are  contagious  and  inoculable  upon  persons  free 
from  syphilitic  taint,  but  neither  are  auto-inoculable. 

Again,  Ricord's  statements  relative  to  tertiary  symptoms  cannot  at  the 
present  day  be  implicitly  received.  This  author  maintains  that  tertiary 
lesions  are  not  inoculable  and  cannot  be  transmitted  by  hereditary  descent 
under  their  peculiar  type,  and  hence  that  the  virus  in  tins  stage  must  be 
entirely  changed  from  its  original  character.  The  first  of  the  above  asser- 
tions is  doubtful,  the  second  incorrect.  The  inoculability  of  tertiary 
symptoms  has  never  been  tested  upon  persons  free  from  syphilitic  taint, 
and  its  possibility,  therefore,  may  yet  be  demonstrated,  as  that  of  secondary 
symptoms  has  been.  Their  transmission  by  hereditary  descent  in  a  few 
instances,  still  preserving  their  peculiar  type,  is  a  known  fact.  The  most 
frequent  instance  of  this  is  the  occurrence  of  syphilitic  hepatitis  and  deep 
tubercles  of  the  subcutaneous  cellular  tissue  in  infants  affected  with  heredi- 
tary syphilis.  Virchow^  has  also  found  small  collections  of  the  deposit 
peculiar  to  tertiary  syphilis  in  the  cerebral  substance  of  children  born  of 
syphilitic  mothers. 

Hunter  attributed  the  difference  in  the  situation  of  eai'ly  and  late  gene- 
ral symptoms  to  the  influence  of  cold,  which,  as  he  supposed,  rend(;red  the 
more  superficial  parts  of  the  body  most  susceptible  to,  and  earliest  affected 
by  the  virus.  This  anatomical  distinction,  without  Hunter's  explanation, 
has  been  retained  in  Ricord's  classification,  in  which  the  skin  and  mucous 
membranes  on  the  one  hand,  and  the  osseous,  fibrous,  and  cellular  tissues 
on  the  other,  are  regarded  as  the  exclusive  seat  of  secondary  and  tertiary 

'  La  syphilis  constitutionnollo,  ti-caduit  dc  rallciucaml  par  lo  Dr.  I'ioanl,  Paris, 
1860,  p."4. 


428  SYPHILIS. 

manifestations  respectively.  But  this  rule  cannot  always  be  maintained, 
since  one  of  the  earliest  symptoms  of  general  syphilis — preceding  in  many 
cases  the  eruption  upon  the  skin — consists  of  pains  resembling  rheumatism, 
some  of  which  are  evidently  seated  in  the  periosteum  (cliiefly  that  of  the 
cranium  and  in  the  neighborhood  of  the  joints),  and  this  tibrous  tissue  has 
l)een  known  to  take  on  acute  inflammatoiy  action  at  this  time.  In  order 
to  avoid  this  dilficulty,  Bassereau  asserts  that  general  syphilis  attacks  in- 
differently the  integumental,  fibrous,  and  osseous  structures  in  all  periods 
of  the  disease,  but  that  the  more  superficial  portions  of  each  are  affected  in 
the  earlier  and  the  deeper  in  the  later  stages. 

A'irchow^  would  exclude  all  consideration  of  situation  from  the  classifi- 
cation of  general  symptoms,  and  has  proposed  a  system  based  upon  the 
nature  of  the  pathological  changes  in  the  difterent  lesions,  but  which  is  too 
widely  at  variance  with  the  ideas  at  present  received  to  meet  with  general 
adoption.  Von  Baerensprung^  offers  a  similar  classification  in  which 
secondary  symptoms  are  made  to  include  those  lesions  which  are  charac- 
terized by  hyperaimia  and  simple  exudation;  and  tertiary  symptoms  those 
in  which  there  is  tubercular  deposit. 

But  it  is  easier  to  pull  down  than  it  is  to  build  up,  and  attempts  in  the 
latter  direction  may  well  be  deferred  until  many  preliminary  points  are 
settled.  Meanwhile,  we  have  every  reason  to  be  satisfied  witli  the  simple 
and  natural  chronological  division  which  forms  the  basis  of  Ricord's  classi- 
fication, and  which  owes  its  excellence  in  a  great  measure  to  the  keen 
powers  of  observation  of  this  truly  eminent  surgeon.  The  few  errors 
which  he  introduced  are  not  essential  to  the  system,  and  may  well  be 
forgotten,  when  we  recollect  his  important  contributions  to  our  knowledge 
of  the  natural  history  of  syphilis. 

The  time  of  the  appearance  of  any  given  syphilitic  lesion  will  be  influ- 
enced in  a  measure  by  the  constitution  of  the  patient,  his  mode  of  life,  and 
the  treatment  to  which  he  is  or  has  been  subjected,  and  can  therefore  be 
determined  only  approximately.  The  following  table  compiled  by  M. 
Martin^  from  the  statistics  of  McCarthy,  Bassereau,  Sigmund,  and  Four- 
nier,  is  however,  of  value  in  exhibiting  the  usual  period  of  development, 
following  the  appearance  of  the  chancre,  of  the  more  important  syphilitic 
lesions  : — 

'  Op.  cit.  2  Annales  de  la  Charite,  vi,  p.  56,  et  vii,  p.  173. 

3  De  I'accident  primitif  do  la  syphilis  constitutionelle,  Paris,  1863,  p.  87. 


INTRODUCTORY    REMARKS. 


429 


Bate  of  usual 

1 
Date  of  earl'st 

Date  of  lates 

Symptoms. 

development. 

development. 

development. 

Roseola 

45th  day 

25th^day 

12th  month 

Papular  eruption 

65th    " 

28th    " 

12th       " 

Mucous  patches  ...... 

70th    " 

30th    " 

18th       " 

Secondary  affections  of  the  fauces 

70th    " 

50th    " 

18th       " 

Vesicular  eruption       ... 

90th    " 

55th    " 

6th       " 

Pustular  eruption        ..... 

80th    " 

45th    " 

4  years 

Rupia 

2  years 

7tli  month 

4     " 

Iritis   

eth  month 

(iOth  day 

13th  month 

Syphilitic  sarcocele     ..... 

12th      " 

(3tli  month 

34th       " 

Periostosis 

(Jth      " 

4th       " 

2  years 

Tubercular  eruption 

3  to  5  years 

3  years 

20     " 

Serpiginous  eruption  .    •     . 

3  to  5     " 

3      " 

20     " 

Gummy  tumors 

4  to  6     " 

4      " 

15     " 

Onychia 

4  to  6     " 

3      " 

22     " 

True  exostosis     ...... 

4  to  6     " 

2      " 

20     " 

Ostitis,  changes  in  the  bones  and  cartilages 

3  to  4     " 

2      " 

41     " 

Perforation  or  destruction  of  the  velum  palati 

3  to  4     " 

2      " 

20     " 

According  to  Bassereau's  statistics,  the  administration  of  mercury  for 
the  primary  lesion  has  a  decided  influence  in  delaying  the  appearance  of 
secondary  manifestations ;  and  I  am  convinced  from  my  own  observations 
that  this  is  the  case.  Admitting  this  to  be  true,  it  may  seem  strange  that 
I  should  deny  the  power  of  the  same  agent  to  altogether  prevent  general 
manifestations.  I  am,  however,  irresistibly  led  to  this  conclusion,  by  the 
fact  that  I  have  never  seen  an  unquestionable  case  of  true  chancre,  which 
was  not  followed,  sooner  or  later,  by  some  general  lesion,  no  matter  what 
treatment  had  been  employed. 

In  most  cases,  when  syphilis  is  abandoned  to  its  natural  course  uninflu- 
enced by  treatment,  the  earliest  general  manifestations  nearly  or  quite  disap- 
pear spontaneously,  and,  after  a  time,  are  succeded  by  another  set,  which, 
in  its  turn,  may  give  place  to  a  third,  and  so  on;  the  number  of  successive 
outbreaks  varying  in  diffei-ent  cases,  and  commonly  being  in  proportion  to 
the  intensity  of  the  action  of  the  virus.  Thus  sypliilis  usually  shows  itself 
not  in  a  continuous,  but  in  an  interrupted  succession  of  lesions, — a  fact 
of  some  importance,  because  too  often  the  reappearance  of  syphilitic  mani- 
festations is  regarded  as  a  relapse,  while  it  is  really  but  the  natural  course 
of  the  disease. 

In  many  cases,  even  in  the  absence  of  treatment,  syphilis  tends  to  self- 
limitation,  and  its  lesions  ultimately  cea.se  to  appear,  leaving  the  patient 
in  a  fair  state  of  health. 


The  Sources  of  Syphilitic  Contagiox. 

The  older  writers  on  syphilis  fully  believed  in  the  contagiousness  not 
only  of  secondary  lesions,  but  also  of  the  sweat,  saliva,  semen,  milk,  blood, 
and  even  the  breath  of  persons  affected  with  general  syphilis.  Hunter, 
founding  his  opinion  u[ion  a  few  unsuccessful  inoculations  of  the  secietion 


430  SYPHILIS. 

of  secomlary  lesions  upon  the  persons  bearing  them,  declared  that  the  power 
of"  contagion  was  confined  to  the  primary  sore.  Auto-inoculations,  similar 
to  those  of  Hunter,  were  repeated  in  thousands  of  instances  by  Ricord,  and, 
in  imitation  of  his  example,  by  numerous  surgeons  in  various  parts  of  the 
world,  the  resvdts  of  which  were  uniformly  unsuccessful  with  scarcely  an 
exception  worthy  of  notice.  On  the  other  hand,  the  chancroid  was  re- 
garded by  Ricord  and  by  the  profession  generally  as  the  chancre-type,  and 
its  secretion  was  found  to  be  inoculable  with  the  greatest  facility.  The 
inference  which  was  drawn  was  a  natural  one,  viz.,  that  a  radical  distinc- 
tion existed  between  primary  and  secondary  lesions  in  the  contagiousness  of 
the  former  and  the  incommunicable  character  of  the  latter  ;  and  the  zeal, 
energy,  and  ability  with  which  this  idea  was  for  many  years  defended  are 
known  to  the  whole  medical  world. 

The  plausibility  of  this  evidence,  the  immense  number  and  uniform 
results  of  the  experiments  resorted  to,  the  keen  powers  of  observation,  in- 
genious reasoning,  attractive  manners,  and  evident  sincerity  of  the  Surgeon 
of  the  Hopital  du  Midi,  united  in  adding  weight  to  a  doctrine  which  had 
ali'eady  been  sanctioned  by  the  great  name  of  Hunter,  and  which  was 
consecpiently  for  a  time  received  as  beyond  dispute.  Yet  cases  in  appa- 
rent contradiction  to  Ricord's  "  law"  were  met  with  by  many  careful  ob- 
servers, especially  in  infants  affected  with  hereditary  syphilis,  whose  early 
age,  incapacitating  them  from  sexual  intercourse,  greatly  diminished  the 
chances  of  error  of  observation  ;  and  although  instances  of  the  transmission 
of  55econdary  lesions  from  the  nursling  to  the  nurse,  and  vice  versa,  wei'C 
explained  away  with  great  ingenuity  by  Ricord  and  his  adherents,  yet  they 
gradually  came  to  be  admitted  by  the  majority  of  the  profession.  At  the 
same  time  it  was  felt  to  be  highly  desirable  to  demonstrate  this  power  of 
contagion  by  experimental  inoculation,  and  thus  place  it  beyond  a  doubt ; 
and  afterwards  to  study  the  phenomena  of  the  process  and  compare  them 
with  those  attending  the  evolution  of  general  syphilis  when  originating  in 
a  chancre.  Until  this  was  done,  the  subject  was  likely  to  remain  an  open 
question. 

This  test,  however,  could  not  readily  be  applied.  Ricord  and  his  school 
liad  confined  their  inoculations  to  persons  already  infected,  and  it  was 
generally  admitted  that  further  experiments,  in  order  to  be  decisive,  must 
l)e  made  upon  those  who  were  free  from  syphilitic  taint — a  course  which 
could  not  be  justified  in  a  moral  point  of  view  even  for  the  purpose  of  ad- 
vancing science.  Wallace  had  already,  in  1835,  succeeded  in  inoculating 
the  secretion  of  condylomata  upon  healtliy  individuals,  but  the  want  of 
precision  in  his  observations  rendered  them  of  little  value.  Subsequent 
inoculations,  however,  by  Waller  of  Prague,  Rinecker  of  Wiirzburg,  a 
surgeon  of  the  Palatinate  who  concealed  his  name,  Gibert  and  Vidal  of 
Paris,  and  others,  settled  this  question  in  fiivor  of  the  contagiousness  of 
secondary  lesions  and  even  of  the  blood  of  syphilitics,  for  all  time.  The 
novelty  of  this  subject  at  the  time  of  the  publication  of  the  earlier  editions 
of  this  work,  led  me  to  give  the  experiments  referred  to  in  detail.     These 


INTRODUCTORY    REMARKS.  431 

will  now  be  omitted,  and  I  shall  content  myself  Avith  a  bare  statement  of 
what  must  be  regarded  as  proved  both  by  clinical  observation  and  artifi- 
cial experiment,  and  what,  moreover,  is  universally  admitted  at  the  pre- 
sent day. 

AVe  must  admit  as  sources  of  syphilitic  contagion — 

1.  The  .secretion  and  the  organic  debris  of  the  primary  lesion  or 
chancre. 

2.  The  same  of  any  of  the  secondary  lesions  of  syphilis,  among  which 
the  various  forms  of  mucous  patches  are  eminently  contagious. 

3.  The  blood  of  persons  in  the  secondary  stage  of  syphilis.  For  the 
absolute  demonstration  of  this  fact  by  actual  experiment  in  1862,  we  are 
indebted  to  Dr.  Pellizari,  Clinical  Prof,  of  Venereal  Diseases  at  the  Ecole 
Pratique  of  Florence. 

It  is  generally  believed  that  tertiary  lesions  are  not  inoculable,  and  per- 
haps no  cases  have  as  yet  been  reported  with  sufficient  accuracy  of  detail 
to  prove  the  contrary ;  but,  as  the  boundary  line  between  secondary  and 
tertiary  syphilis  is  not  definitely  defined,  so  are  the  limits  of  contagion  to 
some  degree  uncertain. 

Admitting  the  contagiousness  of  the  blood  of  syphilitic  persons,  we 
might  from  a  pj-iori  reasoning  suppose  that  the  various  fluids  which  are 
secreted  from  the  blood,  as  the  saliva,  milk,  sweat,  and  semen,  are  also 
contagious,  and  this  was  the  belief  of  the  earlier  writers  on  syphilis.  This 
supposition,  however,  is  not  in  accordance  with  clinical  observation,  and 
has  been  disproved  by  actual  experiment  with  a  number  of  the  secretions 
mentioned.  Diday  inoculated  two  healthy  persons  wath  the  lachrymal 
secretion  taken  from  the  eye  of  a  patient  in  the  height  of  secondary  mani- 
festations ;  the  result  Avas  negative.' 

The  non-inoculability  of  the  semen  of  syphilitics  was  fully  proven  in  a 
number  of  experiments  made  by  Mireur.^  A  number  of  cases,  which  have 
appeared  in  medical  journals  within  a  few  years,  and  which  have  been  sup- 
posed by  their  authors  to  establish  the  contrary,  have  been  so  loosely  ob- 
served as  to  deprive  them  of  any  claim  to  serious  consideration. 

The  innocuity  of  the  milk  is  proved  by  the  fact,  that  a  mother  who  con- 
tracts syphilis  after  the  birth  of  her  child,  may  nurse  that  child  with  im- 
punity, provided  she  has  no  lesion  upon  her  breasts.  Moreover,  Pardova,' 
in  18GG,  attempted  to  inoculate  the  milk  of  eight  syphilitic  women,  by 
pricking  it  into  the  skin,  by  applying  it  to  a  vesicated  surface,  and  even 
by  hypodermic  injection,  and  in  all  without  effect. 

In  sliort,  we  have  no  reason  to  believe  that  any  of  the  normal  secretions 
of  syphilitic  persons,  when  free  from  admixture  with  the  secretions  of 
secondai;y  lesions  or  with  the  blood, — as,  for  instance,  saliva,  not  mixed 
with  the  secretion  of  buccal  mucous  patches, — are  contagious. 

'  Gaz,  med.  de  Lyon,  No.  3,  1865. 

'  Ann.  de  derm,  ct  sypli.,  Paris,  No.  6,  tome  viii,  1877. 

3  Gior.  ital.  d.  mal.  ven.,  Milano,  t.  ii,  p.  153,  1867. 


432  syphilis. 

Tfik  Modes  of  Syphilitic  Contagion. 

Sypliilitic  contagion  may  be  direct  or  mediate,  like  that  of  the  chan- 
croid ;  and  much  that  has  already  been  said  in  reference  to  the  latter  (see 
Part  II,  Chap.  I.),  is  here  applicable. 

Direct  contagion  takes  plac(i  most  fi-equently  from  the  genital  organs  of 
one  person  to  those  of  another  in  sexual  congress,  and  it  is  often  the  result 
of  unnatui-al  and  beastly  modes  of  indulgence  between  persons  of  the  op- 
posite or  the  same  sex.  Hence  arise  many  ciiancres  of  the  anus,  of  the 
tongue,  of  the  fold  between  tlie  breast  and  side  of  the  chest,  etc.  etc.  I 
have  seen  a  chancre  of  the  tonsil  in  a  man,  due  to  inoculation  from  a 
mucous  patch  upon  the  tongue  of  another  man. 

More  innocently,  contagion  takes  place  in  the  contact  of  mouth  to 
month,  as  in  the  act  of  kissing.  Tlie  most  innocent  girls  are  thus  often  con- 
taminated by  the  freedom,  which  is  unfortunately  common  in  some  families 
of  saluting  their  male  visitors  in  this  manner.  The  frequency  with  which 
mucous  patches  in  the  mouths  of  sucklings  will  infect  the  nipples  of  a 
wet-nurse,  is  well  known,  and  the  same  is  sometimes  met  with  in  adults. 
I  recently  prohibited  a  man  who  had  contracted  syphilis  from  having  con- 
nection with  his  wife.  He  obeyed  my  instructions,  but,  thinking  it  safe 
to  suck  her  nipple,  gave  her  a  chancre  in  that  situation.  It  is  commonly 
by  direct  contagion,  that  so  many  sui-geons,  and  especially  accoucheurs, 
contract  chancres  upon  the  fingers  from  contact  with  the  lesions  of  syphilis 
ui)on  their  patients.  The  number  of  such  cases  is  greater  than  is  com- 
monly supposed,  for  the  unfortunate  victims,  although  innocent,  are  usually 
most  careful  to  conceal  their  misfortune.  I  have  known  dentists  to  suffer 
the  same  fate. 

Syphilis  is  also  said  to  have  been  conveyed  in  the  rite  of  circumcision, 
from  mucous  patches  in  the  mouth  of  the  operator  to  the  wound  upon  the 
infant's  penis,  which  it  is  customary  to  suck,  and  Sigmund  has  reported  a 
case  of  this  kind.  In  a  number  of  cases  referred  to  Dr.  R.  W.  Taylor,  he 
was  unable  to  find  sufficient  evidence  of  such  transmission,  although  its 
possibility  cannot  be  doubted.  Dr.  Taylor's  paper'  contains  an  able  resume 
of  the  subject. 

Mediate  contagion  may  occur  from  the  passage  of  a  cigar  or  a  pipe  from 
mouth  to  mouth  ;  from  the  use  of  common  utensils,  as  a  tooth-brush,'* 
wine-glass,  a  cup,  a  spoon,  etc.  etc.,  by  different  persons  ;  from  sleeping  in 
the  same  bed  ;  from  matter  conveyed  on  certain  tools  used  in  manufacture, 
as  the  pipes  of  glass-blowers  (many  instances  of  which  have  been  recorded 
as  having  occurred  in  France  and  have  led  to  the  passage  of  a  law  that 
each  workman  should  have  his  own  mouth-pitice).  Washing  utensils  used 
in  common,  surgical  appliances,  as  sponges,  bandages,  etc.,  and  surgical 

»  N.  York  M.  .J.,  Dec,  1873. 

2  A  case  of  syphilitic  inoculation  by  a  tootli-brush,  by  Dr.  E.  B.  Baxter,  Lancet, 
bond.,  May  31,  1879. 

We  have  also  met  with  a  case  in  which  this  was  probably  the  mode  of  contagion. 


INTRODUCTORY    REMARKS.  433 

instruments,  especially  the  Eustachian  catheter,  are  also  recorded  as  havino- 
been  the  medium  of  contagion. 

In  1877,  Albert  Josias^  reported  a  case  of  the  transmission  of  syphilis 
by  tattooing,  the  instrument  used  for  the  purpose  having  first  been  mois- 
tened in  the  mouth  of  the  operator,  who  had  mucous  patches  in  the  buccal 
cavity.  Since  then  Drs.  Maury  and  Dulles^  have  reported  fifteen  similar 
cases  occurring  in  this  country. 

At  a  late  meeting  of  the  Society  of  Public  Medicine,  in  Paris,  Dr.  Ga- 
lippe  related  a  number  of  cases  of  the  transmission  of  syphilis  through 
children's  toys,  as  whistles  and  trumpets,  which  had  been  blown  upon  by 
the  vendor  before  being  passed  to  the  child.  But  the  different  ways  in 
which  mediate  contagion  may  take  place  are  so  self-evident,  that  it  is  not 
necessary  to  enter  into  them  more  fully.  I  shall,  therefore,  only  briefly 
refer  to  one  which  has  attracted  much  attention  and  which  should  ever  be 
borne  in  mind  ;  I  refer  to  syphilitic  contagion  conveyed  on  the  point  of  the 
lancet  in  performing  vaccination. 

There  is  every  reason  to  believe,  as  stated  in  an  admirable  paper  by 
Viennois,'  that  the  agent  of  contagion  in  these  cases  is  not  the  lymph 
taken  from  the  arm  of  the  syphilitic  infant,  but  the  blood  which  is  often 
drawn  in  collecting  the  lymph,  especially  toward  the  close  of  the  operation 
if  a  number  of  punctures  have  been  made.  Moreover,  because  an  infant 
develops  general  syphilis  after  vaccination,  it  is  not  always  true  that  the 
syphilis  is  due  to  the  vaccination,  since  this  disease  may  have  been  in- 
herited from  its  parents  and  its  appearance  have  been  merely  hastened  by 
the  irritation  of  the  integument  induced  by  the  vaccination.  These  con- 
clusions are  thus  formulated  by  M.  Viennois  : — 

1.  Vaccination  with  pure  vaccine  matter  is  sometimes  the  exciting 
cause  of  the  appearance  of  a  syphilitic  eru[)tion  in  inftinfs  already  tinder 
the  syphilitic  diathesis ;  in  the  same  manner  that  it  gives  rise  to  non-spe- 
cific eruptions  in  strumous  subjects.  The  history  of  the  case  and  the 
order  of  evolution  of  the  symptoms  are  generally  sufficient  to  establish  the 
diagnosis.  For  instance,  the  appearance  of  the  eruption  within  a  few 
days  or  weeks  after  the  vaccination,  without  the  ordinary  period  of  incu- 
bation of  syphilis,  will  render  it  probable  that  the  disease  was  already 
latent  in  the  system. 

2.  Syphilis  cannot  be  transmitted  to  a  healthy  person  by  the  inocula- 
tion of  vaccine  matter  taken  from  a  syphilitic  subject,  unless  the  lancet 
at  the  same  time  be  charged  with  blood  ;  in  which  case  a  ciiancre  is  pro- 
duced, followed  by  general  symptoms  in  tlieir  usual  order  of  evolution. 

It  is  still  believed  by  some  that,  in  these  cases,  the  blood  is  not  tiie  only 
vehicle  of  contagion,  and  that  epidermic  scales,  or  leucocytes,  or  the  secre- 
tion of  an  ulcer  underlying  the  vaccine  vesicle  (liinccker*),  may  also  be 
responsible. 

'  Progres  med.,  Par.,  1877,  p.  205. 

2  Am.  J.  M.  Sc,  Phila.,  Jan.,  1878. 

'  Arch.  gen.  de  med.,  Paris,  jiiin,  18G0. 

»  Vrtljschr.  f.  Dermat.,  Wien,  1878,  p.  25. 
28 


434  SYPHILIS. 

Two  remarkable  instances  of  the  transmission  of  syphilis  by  vaccina- 
tion are  reported  by  jM.  Lecoq.^  By  far  the  most  important  and  interest- 
ing series  of  cases,  liowever,  occurred  at  Rivalta,  Italy,  in  which  forty-six 
out  of  sixty-three  children  who  were  vaccinated  became  syphilitic  and 
transmitted  the  disease  to  nurses,  mothers,  fathers,  brothers,  and  sisters, 
making  a  total  of  eighty  persons.  In  these  cases,  also,  blood  is  said  to 
have  been  drawn  with  the  lymph  from  the  arm  of  the  first  vaccinifer,  and 
the  initial  lesions  in  those  who  received  the  poison  were  indurated  ulcers 
(chancres)  which  were  preceded  by  a  period  of  incubation  averaging 
twenty  days.^ 

Numerous  instances  of  a  similar  character,  in  some  of  which  the  dis- 
ease spread  to  a  large  number  of  persons,  have  been  collected  by  M. 
Viennois,  and  are  sufficient  to  show  that  although  vaccination  is  commonly 
a  harmless  operation,  yet  that  it  may,  if  proper  precaution  be  omitted,  be 
the  means  of  transmitting  a  fearful  constitutional  disease. 

In  the  above  remarks  on  "  vaccino-syphilis,"  it  will  be  seen  that  refer- 
ence has  only  been  made  to  the  conveyance  of  syphilis  from  the  person 
from  whom  the  lymph  was  taken  to  the  person  upon  whom  the  lymph  was 
implanted.-  But  there  is  still  another  danger  in  vaccination  which  had 
nearly  or  entirely  escaped  notice,  until  attention  was  called  to  it  by  Dr. 
R.  W.  Taylor  :  I  refer  to  the  transmission  of  syphilis  by  using  the  same 
instrument  uncleansed  upon  a  number  of  individuals  in  succession,  one  of 
whom  is  syphilitic.  In  performing  vaccination  in  this  manner,  as  is  often 
done  in  charity  institutions,  the  vaccine  matter  may  be  never  so  pure,  but 
the  scarificator  may  be  contaminated  by  contact  with  one  person  under  the 
influence  of  syphilis  and  convey  the  disease  to  the  next.  In  the  case 
re[)orted  with  great  detail  by  Dr.  Taylor,^  a  number  of  the  inmates  of  iTie 
Penitentiary,  Blackwell's  Island,  were  ordered  to  be  vaccinated.  The 
vaccine  was  in  quill  form,  and  furnished  by  the  Board  of  Health.  The 
physician  vaccinated  about  twenty  persons  in  succession,  using  the  same 
scarificator  without  cleansing  it.  The  operation  had  been  done  upon  six 
persons,  when  a  young  prostitute  affected  with  syphilis  was  vaccinated ; 
next  to  her  an  infant,  aged  nine  months.  All  did  well  with  the  exception 
of  this  infant,  in  whom  a  chancre  was  developed  at  the  point  of  inocula- 
tion, followed  by  the  usual  train  of  general  lesions. 

General  Syphilis  alavays  folloavs  a  Chancre. 

In  the  great  majority  of  cases  of  acquired  syphilis  (excluding  those  of 
hereditary  origin),  general  symptoms  can  clearly  be  traced  to  a  preceding 
chancre.     Thus  of  82G  patients  with  general  syphilis  who  were  treated  at 

'  GnvEXoT,  Tli6se  de  Paris,  1859,  Soc  calso  Gaz.  hoLd.  de  nied.,  Paris,  27  janv., 
18tJ0. 

2  For  an  able  resumfe  of  these  cases,  see  Mr.  Henry  Lee's  Lectures  on  Syphilitic 
Inoculation  and  its  Relations  to  Vaccination,  London  Lancet,  1862. 

3  Arch,  of  Dermatol.,  N.  Y.,  vol.  ii,  1876,  p.  203. 


INTRODUCTORY    REMARKS.  435 

the  Hopital  dii  ]Micli  in  185G,  the  previous  existence  of  a  chancre  in  815 
was  established  beyond  a  doubt  either  by  examination  or  by  voluntary 
confession  ;  in  9,  there  was  strong  reason  to  suspect  it ;  and  in  the  remain- 
ing 2,  the  disease  was  evidently  due  to  hereditary  taint.  Of  267  cases  of 
secondary  syphilis  observed  by  Fournier/  the  same  fact  was  proved  in 
265.  Of  198  cases  of  syphilitic  erythema  under  the  care  of  Bassereau,^ 
either  a  chancre  or  unquestionable  traces  of  one  were  seen  in  170  ;  in  19, 
the  patients  confessed  to  the  fact,  although  no  evidence  of  it  was  found 
upon  their  persons  ;  4  acknowledged  having  had  a  gonorrhoea ;  5  declared 
that  they  had  had  no  preceding  lesion.  Thus  we  find  that  in  a  total 
of  1291  cases,  general  syphilis  was  undoubtedly  preceded  by  a  chancre  in 
all  except  22. 

These  statistics  agree  with  the  experience  of  all  physicians,  that,  as  an 
almost  invariable  rule,  syphilis  evidently  originates  in  a  chancre  ;  and  the 
small  number  of  cases  in  which  the  existence  of  the  ulcer  cannot  be  estab- 
lished renders  it  extremely  probable  that  there  are  no  exceptions  to  this 
law,  especially  when  we  take  into  account  the  following  considerations : — • 

Chancres  are  capable  of  spontaneous  cicatrization,  and  all  traces  of  them 
may  disappear  in  time,  even  without  treatment. 

They  may  occupy  unusual  situations,  where  their  presence  may  readily 
escape  notice,  or  be  almost  impossible  to  detect ;  among  which  the  interior 
of  the  urethra,  vagina,  cervix  uteri,  and  the  buccal  and  rectal  cavities  de- 
serve special  mention. 

Exceptional  cases  almost  invariably  rest  upon  the  testimony  of  patients 
alone  ;  and  are  the  more  frequent,  the  later  the  lesion  presented  in  the  order 
of  succession  of  syphilitic  symptoms,  in  other  words,  the  longer  the  time 
which  must  have  elapsed  since  contagion  took  place.  For  instance,  cases 
are  rare  in  which  a  patient  with  syphilitic  erythema  does  not  confess  that 
he  has  had  a  chancre  ;  on  the  contrary,  they  are  not  infrequent  when  the 
general  lesion  is  syphilitic  rupia,  tubercles,  orchitis,  or  periostitis.  This 
fact  leads  us  to  suspect  that  the  defective  memory  of  patients  will  explain 
some  apparent  exceptions  to  the  rule. 

From  various  motives,  patients  often  conceal  facts  within  their  knowl- 
edge. 

With  perfect  memory  and  unquestionable  honesty,  patients  are  incompe- 
tent witnesses  upon  subjects  ivhich  involve  medical  kuoioledye,  xohich  they 
do  not  possess.  The  superficial  chancre — the  form  which  most  frequently 
precedes  general  syphilis — is  so  indolent  and  so  insignificant  a  sore,  that  it 
may  readily  pass  unnoticed,  or,  if  seen,  be  mistaken  for  a  mere  abrasion. 
I  have  met  with  several  instances  in  which  patients  bearing  this  form  of 
cliancre  iq  plain  sight  upon  their  persons,  were  entirely  ignorant  of  its 
pi-esence,  or  thought  it  of  no  consecjuence. 

A  chancre  may  be  overlooked  by  the  patient  because  seated  elsewhere 
than  upon  the  genitals — the   exclusive  seat  of  venereal  ulcers  in  the  esti- 

'  De  la  contagion  sypliilitique,  Paris,  1860,  p.  15.  2  Op.  cit.  p.  103. 


436  SYPHILIS. 

mation  of  the  public — or  may  not  be  discovered,  because  concealed  within 
the  vagina,  or  beneath  the  prepuce  when  phimosis  is  present,  or  when  the 
glaus  is  never  uncovered.  In  many  instances  married  men  have  applied  to 
me  with  chancres,  and  within  a  few  months  their  wives  have  exhibited  tlie 
early  symptoms  of  general  syphilis,  without  having  noticed  or  suspected 
the  presence  of  a  chancre  wliicli  undoubtedly  existed,  but  which  fear  of 
exposing  tlie  iiusbands  prevented  my  searching  for.  In  other  cases  where 
an  examination  has  been  made,  I  have  found  chancres  of  which  the  patients 
were  entirely  ignorant. 

Again,  chancres  sometimes  occur  within  the  urethra  beyond  the  reach 
of  vision,  where  an  unprofessional  person  cannot  be  expected  to  be  aware 
of  their  presence  from  the  slight  discharge,  pain  in  micturition,  and  indu- 
ration, which  constitute  their  only  symptoms,  and  wliicli  may  be  obscured 
by  a  coexisting  gonorrhoea. 

I  repeat,' therefore,  that  when  we  consider  in  how  great  a  proportion 
of  cases  general  lesions  are  known  to  have  been  preceded  by  a  chancre, 
and  when  we  reflect  upon  the  numerous  sources  of  error  attending  the 
testimony  of  patients  in  apparently  exceptional  cases,  it  is  infinitely  pro- 
bable that  a  law  which  is  known  to  be  commonly  true,  is  in  fact  invariable, 
and  that  general  syphilis  always  follows  a  chancre. 

Syphilis  pursues  essentially  the  same  course,  wiiErnER  derived 
FROM  A  Primary  or  Secondary  Symptom;  in  the  latter  case, 
AS  in  the  former,  the  initial  lesion  is  a  Chancre. 

This  proposition  may  almost  be  said  to  be  self-evident,  for  wlio  would 
ever  dream  tiiat  a  case  of  scarlet  fever,  measles,  or  smallpox  would  vary 
in  its  symptoms  according  as  it  was  contracted  from  a  person  in  the  early 
or  the  late  stage  of  the  same  disease?  We  are  surprised,  therefore,  when 
we  look  back  only  a  few  years  to  the  time  when  some  of  the  most  eminent 
authorities  maintained  that  contagion  from  a  chancre  would  indeed  produce 
a  chancre,  but  that  contagion  from  a  mucous  patch  would  produce  a  mucous 
patch,  etc.;  equally  surprised  must  we  be  at  the  incredulity  with  which 
tliis  proposition  was  met  on  its  first  announcement,  in  185G,  by  Dr. 
Edward  Langlebert,  at  a  meeting  of  the  Societe  Medicale  du  Pantheon,  of 
Paris.^  Langlebert's  paper,  however,  contained  no  adequate  proof  and 
was  nearly  forgotten,  when  the  subject  was  again  taken  up  by  Kollet,^  who 
adduced  such  an  amount  of  evidence  in  favor  of  this  proposition  as  to  leave 
no  doubt  of  its  truth.  It  is  unnecessary  at  the  present  day  to  dwell  upon 
tills  subject;  suffice  it  to  say  that,  as  sliown  by  many  cases  of  artificial 
inoculation,  tlie  results  of  syphilitic  contagion  are  the  same  whether  the 
matter  be  taken  from  a  primary  or  a  secondary  lesion. 

'  Proceedings  of  the  above  Society  for  1856,  p.  8.     See  also  a  letter  from  M, 
]-an<rl(!bert  to  M.  Diday,  Gaz.  nied.  de  Lyon,  July  1,  1859. 
2  Arch.  gen.  de  med.,  Paris,  fev.,  mars,  et  avril,  1859. 


INTRODUCTORY    REMARKS. 


437 


Syphilis  has  a  second  period  of  incubation  (between  the  appearance 
of  the  chancre  and  the  development  of  general  lesions)  avhich,  al- 
though subject  to  some  variation,  is  not  indefinite  in  its 
duration. 

It  was  at  one  time  erroneously  supposed  that  the  first  general  manifes- 
tations of  syphilis  might  make  their  appearance  at  any  period  subsequent 
to  contagion  and  to  the  development  of  the  initial  lesion ;  hence,  that  a 
man  who  had  once  contracted  a  chancre  was  never  safe,  no  matter  how 
long  a  time  had  been  passed  without  any  further  evidence  of  the  disease. 
It  is  now  known  that  if  general  manifestations  are  ever  to  appear  they 
will  show  themselves  within  a  comparatively  limited  period. 

In  studying  any  case  or  series  of  cases  with  reference  to  this  point,  the 
following  conditions  should  be  observed: — 

1.  That  the  date  of  the  infecting  coitus  or  of  the  appearance  of  the 
chancre  should  be  known. 

2.  That  the  patients  have  not  been  subjected  to  treatment  which  may 
delay  and,  in  the  opinion  of  some,  entirely  prevent  the  appearance  of 
general  lesions. 

3.  That  they  have  been  under  the  observation  of  some  one  competent 
to  discover  the  earliest  manifestation  of  general  syphilis. 

These  conditions  were  carfully  fulfilled  in  fifty-two  cases  observed  by 
Diday,^  who  arrived  at  the  following  results  : — 


No.  OF  Cases. 

IXTERVAL  IS  DATS 

1 

25 

1 

28 

1 

33 

2 

35 

3 

3« 

1 

37 

4 

38 

1 

39 

1 

40 

1 

41 

1 

42 

1 

44 

10 

45 

2 

46 

No.  OF  Cases.   Interval  i 

4 

47 

4 

48 

3 

50 

1 

52 

1 

54 

2 

56 

1 

57 

2 

58 

1 

60 

1 

63 

1 

70 

1 

105 

Total,  52 

It  appears  from  tliis  table  that  the  shortest  [)eriod  of  incubation  was  2o 
days,  and  tb.e  longest  lOo  days,  but  that  the  latter  was  3">  days  more  than 
the  one  immediately  preceding  it.  Tlie  extreme  limits  of  variation  are 
not  widely  .separated  (certainly  not  if  compared  witli  the  variation  from  a 
few  weeks  to  thirty  years,  whicli  is  given  by  some  authors),  and  we  find 
on  examination  tliat  in  by  far  the  larger  proportion  of  cases,  tlie  periods  of 
incubation  terminated  witliin  two  weeks  of  each  other;  thus  in  38  of  the 
52  cases,  or  in  about  four-fifths,  this  period  was  from  3o  to  50  days. 
Taking  the  average  of  the  whole  number,  it  was  4G  days. 


Nouvellcs  doctrines  sur  la  syjihilis,  p.  265. 


438  SYPHILIS. 

Similar  testimony  is  given  by  Bassereau/  Victor  de  Meric,^  Fournier,^ 
MacCarthy,*  Sigmund,^  Kicord,''  and  others. 

The  testimony  derived  from  artificial  inoculation  (which  has  the  advan- 
tage that  all  the  steps  of  the  process  ai'e  under  the  dii'ect  observation  of  the 
surgeon)  is  essentially  the  same.  Thus  in  12  cases  of  inoculation  of  the 
secretion  of  a  chancre,  the  mean  length  of  the  second  period  of  incubation 
was  48  days;  in  14  cases,  in  which  the  secretion  of  various  lesions  of  the 
skin  and  mucous  membranes  was  employed,  it  was  45  days;  in  4  cases, 
however,  in  which  the  matter  was  taken  from  pustules,  it  was  82  days. 

In  my  own  practice,  I  have  learned  to  regard  the  appearance  of 
secondary  symptoms  between  the  fortieth  and  fiftieth  day  after  the  de- 
velopment of  the  chancre  as  almost  certain,  and  I  have  never  seen  a  case 
which  was  carefully  watched,  in  which  they  failed  to  show  themselves 
within  three  months.  Ricord's  limit  of  "'  six  months"  will  certainly  include 
the  most  extreme  cases. 

The  conclusions  at  which  we  have  arrived  furnish  the  strongest  induce- 
ment in  all  ulcers  of  a  doubtful  character  to  defer  general  treatment,  and 
keep  the  patient  under  careful  observation  until  the  time  lor  secondary 
symptoms  to  appear  is  passed. 

To  sum  up  tills  whole  matter  : — 

A  venereal  ulcer  which  is  not  subjected  to  specijic  treatment  (so  called) 
ivill  usnalli/,  if  at  all,  be  followed  by  secondary  symptoms  within  fifty  days, 
and  always  icithin  six  months. 

It  follows  as  a  corollary  from  this  proposition  that 

The  earliest  symjjtoms  of  general  syphilis  (excej)t  in  cases  of  hereditary 
origin)  have  been  preceded  by  a  chancre,  probably  within  fifty  days,  and 
certainly  ivithin  six  months. 

I  will  merely  add  that  the  development  of  general  syphilis  is  hastened 
by  an  elevated  temperature,  and  by  those  causes  which  tend  to  depress  the 
vital  powers,  as  excessive  or  prolonged  exertion,  or  a  dissipated  course  of 
lite;  and  tiiat  it  is,  on  the  other  hand,  retarded  by  the  contrary  influences, 
and  also  by  the  supervention  of  an  acute  disease,  as  continued  fever,  in- 
flammation of  the  lungs,  etc.  It  also  appears  to  be  earlier  in  women,  in 
whom  mucous  patches  are  developed  with  great  rapidity,  sometimes  even 
three  weeks  after  the  chancre. 

•  Op.  cit.,  p.  176.  2  Lettsomifin  Lectures,  1858,  p.  31. 

'  Notes  to  Ricord's  L(>9ons  sur  le  chancre,  2d  ed.  p.  46(5. 
<  These  de  Paris,  1844.  s  -wieii  Wochenschrilt,  1856. 

6  Lettres  sur  la  syphilis,  2d  ed.  p.  300. 


THE    NATURE    OF    SYPHILIS.  439 


CHAPTER    II. 

THE    NATURE    OF    SYPHILIS. 

Ix  its  nosological  relations  syphilis  has  been  called  a  contagious  and  a 
virulent  disease,  a  specific  fever  allied  to  the  exanthemata,  a  disease  of  the 
lymphatics,  a  disease  originating  in  a  fungus,  a  purulent  diathesis  (Des- 
pres),  and  a  blood  disorder. 

Although  these  appellations,  with  the  exception  of  the  purulent  diathesis, 
are  applicable  in  a  restricted  sense,  they  are  all  of  them  more  or  less  incor- 
rect and  unsatisfactory.  It  is  true  that  acquired  syphilis  is  communica- 
ble through  the  blood  and  certain  secretions  which  are  contagious,  but 
this  is  only  a  comparatively  minor  feature  of  the  disease. 

The  same  remarks  apply  with  even  more  force  to  the  term  virulent, 
since  the  only  reason  for  using  it  is  that  virulent  diseases,  like  glanders, 
farcy,  and  hydrophobia,  are  transmitted  by  means  of  a  morbid  secretion 
termed  virus,  and  have  periods  of  incubation.  There  is,  however,  no 
pathological  resemblance,  much  less  a  relation,  between  syphilis  and  these 
diseases. 

Though  the  adoption  of  the  term  *'  specific  fever"  in  classifying  syphilis 
is  urged  even  by  celebrated  syphilographers,  a  careful  examination  and 
comparison  of  the  course  of  syphilis  and  of  the  exanthemata  shows  only 
certain  resemblances  in  prominent,  but  from  a  pathological  view,  merely 
accessory  features.  Syphilis  originates  in  a  fixed  contagion  ;  the  exan- 
themata likewise  in  a  volatile  or  fixed  contagion  ;  they  have  periods  of 
incubation ;  syphilis  two,  the  exanthemata  one,  which  are  followed  by 
constitutional  disturbance  and  fever ;  syphilis  in  this  feature  being  com- 
paratively mild.  Further  tliey  all  have  extensive  integumentary  and 
mucous  membrane  lesions,  which  in  the  exanthemata  are  always  inflam- 
matory during  their  whole  course,  while  in  syphilis  they  are  moderately 
hypera;mic  and  essentially  proliferative.  Here  is  a  radical  point  of  differ- 
ence ;  the  exanthematous  eruptions  are  simply  inflammatory,  and  if  cell- 
proliferation  occurs  it  is  of  a  simple  nature,  a  mere  increase  of  the  normal 
cells.  The  opposite  occurs  in  syphilis;  the  inflammatory  processs  is  less 
active  and  always  results  in  infiltration  of  new  cells  entirely  foreign  in 
their  nature. 

In  order  to  complete  the  comparison  which  places  syphilis  in  the  group 
of  specific  fevers,  it  is  urged  by  the  chief  advocate  of  this  view,  Mr.  Hutch- 
inson, of  London,  that  the  late  or  tertiary  lesions  of  syphilis  have  tiieir 
analogue  in  the  sequela?  which  sometimes  follow  the  exanthemata,  and, 
instead  of  calling  them  tertiary  lesions,  he  woidil  call  tiiem  sequeUii.     Ac- 


440  THE    NATURE    OF    SYPHILIS. 

cording  to  this  view,  syphilis  ends  with  tlie  secondary  period,  and  all  sub- 
sequent lesions  are  not,  as  we  believe  them  to  be,  new,  pathological  pro- 
cesses originating  in  the  one  virus,  but  they  are  simply  non-specific  tissue- 
changes  induced  by  the  previous  ones  in  the  secondary  stage.  Not  only 
is  this  comparison  false,  but  it  is  founded  on  false  assumptions.  The 
sequela?  of  the  exanthemata  are  simple  tissue  changes,  resulting  without 
doubt  from  inflammatory  processes  ;  they  are  in  fact  true  sequelae,  and  are 
etiologically  related  to  the  acute  stage  of  the  disease.  Now  tertiary  lesions 
are  simply  a  late  series  of  specific  pathological  processes  following,  at  vary- 
ing intervals,  somewhat  similar  processes,  called  secondary  lesions,  which 
are  etiologically  related  to  the  same  morbid  cause,  the  syphilitic  diathesis. 
We  can  scarcely  imagine  a  greater  difference.  The  one  is  a  simple, 
chronic,  inflammatory  process  depending  on  acute  antecedent  inflamma- 
tion ;  the  other  is  the  definite  and  late  expression  of  a  diathesis,  which 
manifests  itself  by  a  series  of  proliferative  lesions  separated  by  varying 
periods  of  time. 

Although  the  lymphatic  vessels  and  ganglia  are  largely  affected  by 
syphilis,  and  although  they  are  the  means  of  its  diffusion  and  probably  its 
occasional  depots  of  deposit,  this  relationship,  though  intimate,  is  but  trans- 
itory, since  the  full  development  of  syphilis  takes  place  not  in  the  tissues 
of  either  vessels  or  ganglia  but  in  the  connective  tissue  to  which  these  are 
freely  distributed.  Syphilis  cannot  therefore  be  classed  among  diseases  of 
the  lymphatics. 

It  would  be  a  waste  of  time  to  entertain  the  probability  of  syphilis  being 
caused  by  a  fungus.  It  was  claimed  by  Salisbury,  some  years  ago,  that 
the  disease  had  its  origin  in  a  certain  fungus,  the  "  crypta  syphilitica" 
which  he  said  he  found  in  the  blood  during  the  activity  of  the  diathesis, 
and  which  he  did  not  see  when  the  disease  was  cured.  Since  no  one  else 
has  been  able  to  find  this  source  of  the  disease,  we  conclude  that  it  does 
not  exist,  and  that  the  specimens,  upon  the  study  of  which  the  theory  was 
based,  were  those  of  syphilitic  blood,  into  which,  owing  perhaps  to  care- 
lessness of  preparation  and  exposure,  fungus  growths  had  permeated  and 
fructified, 

Perliaps  the  most  remarkable  theory  of  the  nature  of  syphilis  is  that  of 
Despres,  who,  in  a  work  of  over  500  pages,  elaborates  the  assertion  that 
syphilis  is  a  purulent  diathesis;  that  the  blood  is  contaminated  by  an 
animal  poison  containing  the  syphilitic  elements  ;  that  it  is  altered  little 
by  little  by  contact  of  the  debris  of  syphilitic  pus  with  its  globules,  thus 
infecting  them,  and  multiplying  the  poison,  which  seeks  to  escape  by  the 
skin  in  the  form  of  eruptions.  Among  humoralists,  this  author  goes  to  an 
absurd  extreme.  His  work  need  only  be  mentioned  to  condemn  it  as  a  piece 
of  theorizing,  utterly  at  variance  witii  facts,  and  not  supported  by  any  tenable 
simile.  Tlie  truth  is,  tliat  of  all  diseases,  syphilis  is  essentially  the  least 
purulent.  It  is  not  so  in  its  origin,  since  the  unirritated  secretion  of  the 
initial  lesion  never  contains  pus ;  its  most  extensive  lesions  are  peculiar  in 
the  fact  that  pus  is  rarely  present,  and  then  only  accidentally.  Further, 
the  course  of  purulent  infection  is  widely  different  from  that  of  syphilis. 


THE    NATURE    OF    SYPHILIS.  441 

Lastly,  syphilis,  according  to  the  views  of  humoral  pathology,  is  a  blood 
disease.  The  main  fact  in  support  of  this  opinion  is  that  its  contagion  is 
in  some  stages  transmissible  through  this  fluid,  yet  we  must  admit  the 
qualification  that  this  is  true  only  at  certain  times.  In  order  to  prove 
that  it  is  not  in  its  essence  a  blood  disease,  we  must  show  what  form  of 
disease  it  is.  Weliave  found  that  it  originates  in  the  secretions  of  active 
lesions  and  in  the  blood  during  an  active  stage  of  syphilis.  These  fluids 
inserted  beneath  the  integument  do  not  at  once  pass  into  the  circulation 
but  cause  a  local  cell-increase,  which  forms  a  peculiar  circumscribed  tissue 
entirely  foreign  to  the  parts.  We  then  have  a  local  new  growth  wliich  is 
limited  but  exuberant.  Remaining  local  until  mature,  this  tissue  or 
initial  lesion  passes  away,  having  been  accompanied  by  marked  indurated 
enlargement  of  neigliboring  lymphatics.  Such  being  the  facts,  the  pre- 
sumption is  that  these  new  cells  have,  like  those  of  cancer  and  sarcoma, 
passed  into  and  infected  the  lymphatic  ganglia.  That  here,  owing  to  the 
profusion  of  lympliatic  globules,  which  we  know  to  be  protoplasm,  or 
living  matter  of  the  most  active  kind,  this  new  tissue,  or  rather  these  new 
cells,  undergo  great  change,  increasing  in  numbers  according  to  the  suscep- 
tibility of  the  patient.  Having  been  thus  proliferated,  these  cells  are  now 
taken  into  the  blood,  either  gradually  or  suddenly,  and  by  it  are  carried 
over  the  body,  chiefly,  however,  at  first  to  the  periphery,  where  they  are 
deposited. 

Being  deposited  in  the  connective  tissue,  they  take  root  in  this  soil, 
which  is  peculiarly  susceptible  to  the  influence  of  the  syphilitic  diathesis. 
Here  they  luxuriate,  and  are  stiU  further  developed,  not  attacking  pri- 
marily other  tissues.  Inducing,  in  scattered  circumscribed  spots,  cell- 
proliferation  in  the  middle  layer  of  the  blastoderm,  they  cause  increase  of 
the  cells  of  this  connective  tissue  itself,  as  well  as  the  development  of  a 
new  tissue,  the  granulation  tissue,  also  called  gummatous  tissue,  gumma, 
and  syphiloma.  This  is  a  young  transitory  tissue  composed  of  cells,  some- 
times called  cyto-hlastonies  and  ryto-blastions,  which  resemble  white  cor- 
puscles. In  describing  their  development,  Virchow  says  :  "  The  j)rocess 
begins  by  a  proliferation  of  cells  which  augment  in  volume  (liypertrophy), 
and  of  which  the  nuclei  are  multiplied,  often  in  an  astonishing  manner. 
Then  follows  segmentation  of  these  cells,  and  finally  the  veritable  develop- 
ment, ordinarily,  the  production  of  numerous  cells  which  in  general  are 
very  small  and  usually  contain  nuclei,  these  latter  being  large  and  for  the 
most  part  round.  They  have  a  certain  resemblance  to  the  lymphatic 
globules,  and  have  been  heretofore  called  lymph-corpuscles  or  exudation- 
corpuscles,  as  they  were  thought  to  be  due  directly  to  this  process.  On 
cutting  such  a  tissue,  we  find  a  great  number  of  free  nuclei,  which  are 
round  -or  oblong,  pale,  slightly  granular,  and  containing  one  or  more 
nucleoli.  In  short,  it  is  essentially  a  young  production,  but  slightly  ad- 
vanced in  development,  and  especially  indifferent  in  its  cellular  nature." 
This  description  applies  to  a  gummy  tumor  of  recent  date.  Such  a  tissue 
is  not  always  sliar[)ly  limited  and  compact,  but  is  infiltrated;  its  sliape 
being  moulded  by  the  surrounding  parts.     In  old  cases,  however,  there  is 


442  THE    NATURE    OF    SYPHILIS. 

often  !i  collection  of  fully  developed  cells,  with  but  few  free  nuclei.  Among 
them  may  he  stellate  and  fusiform  cells,  and,  frequently,  Baumgarten  has 
clearly  shown  that  giant  cells,  foi-merly  considered  distinctive  of  tubercu- 
lous infiltration,  are  found  also  in  these  tumors. 

These  stellate  and  fusiform  cells  are  distributed  through  the  tumor, 
■which  is  frequently  traversed  by  an  intercellular  substance  which  is  some- 
times fibrous.  In  some  instances  these  tumors  merge  gradually  into  the 
surrounding  parts,  while  in  others  they  are  encapsulated.  Their  structure 
varies  in  compactness ;  they  may  be  firm  and  fibrous  or  they  may  have  a 
gelatinous  consistence,  resembling  mucous  tissue.  Such  is  the  general 
formation  of  syphilitic  tumors;  it  must  be  remembered,  however,  that  their 
structure  depends  largely  upon  the  configuration  of  the  region  in  which 
they  are  developed  and  the  arrangement  of  its  anatomical  elements.  In 
the  development  of  these  tumors,  as  well  as  of  syphilitic  papules  and  tuber- 
cles, the  fir^t  morbid  change  is  in  the  adventitia  of  the  vessels. 

The  description  here  given  applies  to  the  fully  developed  gummy  tumor. 
The  cells  of  the  earlier  stages  are  mainly  similar.  Tiiose  of  the  initial 
lesion  are  mingled  with  molecules  of  fibrine,  showing  a  more  inflammatory 
process,  while  those  of  tubercles  form  infiltrations  rather  than  distinct 
tumors.  All  of  these  cell-changes  are  similar  and  etiologically  related. 
The  cells,  being  immature,  are  liable  to  fatty  degeneration,  and  for  this 
reason  syphilitic  lesions  often  disappear  spontaneously.  These  cells  belong 
to  the  group  called  by  Virchow  granuloma^  which  also  includes  the  tumors 
of  lupus  and  leprosy.  The  cells  of  each  of  these  diseases  are  similar  and 
resemble  those  of  granulation  tissue.  Those  of  syphilis  are  peculiar  in 
their  arrangement,  mode  of  develo[)ment  and  course,  and  in  being  absorbed 
under  the  influence  of  mercury.  An  important  and  almost  unansweraille 
question  is,  whether  these  cells  of  syphilis  are  specific.  They  are  so  re- 
garded by  Wagner,  who  gives  the  name  "  syphiloma'''  to  the  tissue  which 
they  form.  Virchow,  on  the  contrary,  denies  their  sjjecific  nature,  and  pre- 
fers the  terms  ^''  gumma"  and  '■^granuloma.''  Although  the  appearance  of 
these  tumors  is  almost  identical,  it  must  be  acknowledged  that  tiie  property 
of  contagiousness  is  peculiar  to  the  cells  of  the  syphilitic  tumors. 

We  now  come  to  the  consideration  of  hypera^mia.  Chronic  congestion 
is  an  important  feature  in  the  pathology  of  syphilis.  It  is  especially  notice- 
abhi  in  the  early  stage,  and  is  best  exemplified  in  the  exanthematous  syph- 
ilide  and  in  the  hyperiemia  of  the  fauces.  Many  other  secondary  symptoms 
have  a  similar  nature,  and  hypera^mia  of  the  viscera  probably  occurs  in  this 
stage,  yet  generally  it  altogether  escai)es  observation.  Early  in  syph- 
ilis, this  hyperajmia  precedes  and  accompanies  the  extensive  lesions,  though 
it  may  exist  merely  as  capillary  stasis  without  cell  change.  In  the  late 
stages,  the  hyperiemia  is  milder  and  more  localized.  It  is  probably  alvvays 
a  forerunner  of  gummy  tumors. 

An  additional  phenomenon  of  syi)liilis  is  the  production  of  connective 
tissue,  either  without  gummatous  cells  or  accompanying  gummy  tumors. 
This  tissue  increase  is  the  result  of  mild  hypenemia,  and  occurs  in  firm, 
fibrous  tissues,  such  as  the  periosteum  and  the  capsules  of  the  viscera.     It 


THE    NATURE    OF    SYPHILIS,  443 

is  best  seen  in  syphilitic  periostitis  and  in  the  fibrous  bands  observed  in  the 
liver,  spleen,  lungs,  and  testicles. 

It  is  noticeable  that  suppuration  rarely  accompanies  syphilitic  lesions  ; 
•when  it  does,  as  in  the  early  pustular  eruptions,  it  is  a  secondary  result 
or  an  accidental  occurrence,  and  is  not  an  essential  part  of  the  syphilitic 
process. 

Although  it  was  long  since  claimed  that  the  lymphatics  were  the  active 
agents  in  syphilitic  infection,  and  although  Virchow  has  for  years  insisted 
upon  a  similar  theory,  the  question  has  never  been  properly  studied,  and 
modern  authors  are  vague  and  uncertain  in  their  opinions.  The  majoi-ity, 
however,  regard  the  blood  rather  than  the  lymphatics  as  the  vehicle  of 
contagion.^ 

Our  own  conclusion  is  that  syphilis  is  a  disease  of  the  connective  tissue, 
and  not  primarily  of  the  lymphatics  or  of  the  bloodvessels,  although  the 
blood  may  be  temporarily  modified  and  may  be  the  vehicle  of  contagion. 

The  secretions  of  syphilitic  lesions  are  found  to  consist  of  a  serous  fluid 
containing  numerous  sliining  granules  or  molecules,  which  are  masses  of 
proto[)lasm  or  germinal  matter,  holding  the  contagious  properties  of  syphilis. 
These  microscopic  bodies  are  probably  taken  into  the  circulation  by  the 
lymphatics  and  conveyed  over  the  body.  Possibly  they  are  absorbed  by 
the  blood  corpuscles,  or  the  latter  are  infected  in  some  mysterious  manner 
by  these  actively  increasing  morbid  cells.  The  fact  tliat  serum  alone  does 
not  convey  the  sy[)hilitic  poison  goes  to  prove  that  the  corpuscles  hold 
the  contagious  material. 

In  the  secondary  period  of  sypliilis  these  cells  are  very  numerous,  and 
the  body  may  be  covered  with  papules  and  tubercles  composed  of  them. 
As  the  disease  wanes,  these  lesions  become  more  localized  and  fewer  in 
number,  and  the  blood  is  less  contagious.  Finally  these  cells  may  be 
limited  to  a  few  gummous  tumors;  the  blood  no  longer  carries  the  mole- 
cules, and  it  loses  its  contagious  properties.  The  cells  no  longer  have  a 
tendency  to  reproduction,  which  characterizes  them  in  the  early  stages, 
but  rather  degenerate.  Hence  we  consider  the  blood  and  the  secretions 
in  tertiary  sy})hilis  innocuous.  Even  if  cells  are  present,  they  are  old  and 
inactive,  and  are  incapable  of  reproducing  themselves.     Lancereaux  states 

'  In  the  year  1871,  Dr.  F.  N.  Otis  published  two  articles,  endeavoring  to  explain 
the  periods  of  incubation  and  the  course  of  syphilis  upon  the  theory  that  infection 
occurs  only  through  the  lymphatics.  Assuming  the  syi)liilitic  virus  to  consist  of 
disease-germs,  the  aiithor  thinks  tliat  the  first  period  of  incubation  is  occupied  in 
their  passage  through  the  tissucss,  the  process  varying  induration  in  proportion  to 
the  de])tli  of  the  lymphatics  and  the  resistance  of  the  tissues.  He  believes  that 
the  syphilitic  virus  coagulates  the  superficial  tissue-fluids,  causing  obstruction  to 
the  circulation  and  attraction  to  the  spot  of  wandering  white  corpuscles,  which  by 
their  ama'boid  movement  entrap  the  specific  disease  germs.  The  latter  are  de- 
veloped and  increase  within  the  white  corpuscles,  which  themselves  multiply. 
According  to  this  view,  the  initial  nodule  is  simply  an  aggregation  of  diseased 
white  corpuscles.  These  latter  pass  into  the  ganglia  and  there  again  multiply, 
passing  finally  from  the  lymphatics  into  the  circulation. 


444  THE    NATURE    OF    SYPHILIS. 

that  he  has  often  punctured  himself  in  making  autopsies  on  subjects  with 
gummy  tumors,  and  lias  never  seen  any  bad  result. 

The  periods  of  latency  observed  in  the  course  of  syphilis  are  of  interest, 
and  may  perhaps  be  explained  in  the  following  way.  Each  outburst  is 
attended  by  the  development  and  multiplication  of  the  peculiar  cells,  which 
run  their  course  and  are  finally  absorbed.  Some  remain  and  after  a  time 
are  excited  by  unknown  causes  to  activity.  Thus  repeated  exacerbations 
may  occur,  each  one  depending  upon  the  multiplication  of  cells  remaining 
from  a  previous  outburst.  But  each  relapse  is  less  active  and  less  pro- 
longed than  its  predecessor,  until  perhaps  only  one  nodule,  and  that  com- 
]>osed  of  effete  cells,  may  remain.  The  disease  is  then  cured.  This 
explanation  may  seem  to  apply  imperfectly  to  those  cases  of  prolonged 
latency  in  which  no  lesion  whatever  has  been  perceptible.  Virchow  thinks 
that  in  these  cases  the  lymphatic  ganglia  have  been  the  places  of  deposit  of 
the  syphilitic  cells,  which,  at  the  expiration  of  the  period  of  latency, 
undergo  the  changes  mentioned.  In  any  case,  the  specific  cells  must  be 
hidden  away  somewhere  in  the  system,  since  the  continuance  of  the  disease 
depends  upon  their  existence. 

With  this  view  of  the  nature  of  syphilis,  its  effect  upon  the  health  and 
upon  the  organs  and  tissues  may  be  readily  comprehended.  In  the  early 
active  stage  of  proliferation  the  red  globules  are  diminished  and  the  white 
increased  in  number.  The  depressing  influence  of  syphilis  is  thus  fully 
accounted  for.  Digestion  is  impaired  and  the  tissues  are  poorly  nourished. 
Finally,  the  functions  of  vital  organs  may  be  perverted  or  destroyed  by 
the  cell-changes  produced. 


INITIAL    LESION    OF    SYPHILIS.  445 


CHAPTER    III. 

THEIXITIALLESION   OF    SYPHILIS,  OR   CHAXCRE. 

Logical  accuracy  as  well  as  simplicity  and  perspicuity  of  language 
require  the  abandonment  of  the  terms  "  hard,"  "indurated,"  and  "  infect- 
ing chancre,"  as  applied  to  the  initial  lesion  of  syphilis,  which  should  be 
called  simply  by  the  name  of  chancre,  syphilitdc  chancre,  initial  lesion  of 
syphilis,  or  primary  syphilitic  ulcer.  If  the  name  "  Hunterian  chan- 
cre" be  retained,  it  should  be  applied  exclusively  to  the  less  frequent  form 
of  chancre  which  Hunter  designated,  and  which  is  characterized,  in  addi- 
tion to  the  induration  common  to  all  forms  of  chancre,  by  a  degree  of 
ulcei'ation  that  involves  the  whole  thickness  of  the  skin  or  mucous  mem- 
brane. The  term  "  infecting  chancre"  is  especially  objectionable,  as  it 
implies  that  it  is  the  chancre  which  infects,  whereas  the  very  development 
of  this  sore  is  the  result  of  constitutional  infection.  As  Diday  remarks, 
when  a  man  contracts  syphilis,  the  only  chanci-e  that  can  properly  be 
called  infecting  is  the  one  upon  the  woman  who  gave  him  the  disease. 

For  a  comparison  of  the  frequency  of  the  initial  lesion  of  syphilis  with 
that  of  the  chancroid,  the  reader  is  referred  to  the  first  chapter  of  the 
second  part  of  this  work,  where  the  remarks  upon  the  seat  of  the  chancroid 
are  also  applicable  in  the  main  to  the  sore  under  consideration.  The  fol- 
lowing table  exhibits  the  seat  of  471  chancres  in  men,  comprising  all  that 
were  observed  at  the  Hopital  du  Midi  in  the  year  1856  : — 

Chancres  on  the  glans  and  prepuce     ......  314 

"  oil  the  skill  of  the  penis       ......     (JO 

"  oil  various  parts  of  the  penis        .         .         .         .         .11 

"  involving  the  meatus  .......     32 

"  within  the  urethra  (not  visible  on  forced  separation  of 

the  lips  of  the  meatus,  but  recognized  by  pali)atioii, 
inflammation  of  the  lymphatics,  etc.)       .         .         .17 
"  on  the  scrotum  and  peiio-scrotal  angle  .         .         .11 

"  of  tlie  anus  ........       6 

lips 12 

"  "       tongue 8 

"  "        nose 1 

"  "        pituitary  membrane ......       1 

"  "        eyelid 1 

"  "        fingers        ........       1 

"  "leg 1 

Total         .         .         .         .471 

In  1.30  women  aflfected  with  true  chancres  at  the  Antiquaille  Hospital, 
Lyons,  where  wet-nurses  are  admitted,  M.  Carrier  found  the  seat  to  be  : — 


446  INITIAL    LESION    OF    SYPHILIS. 

Times. 

The  labia  majora         .........  43 

"    entrance  of  the  vagina          .......  12 

"    meatus          ..........  14 

"    nymphre        ..........  10 

"    fourchette     ..........  7 

"    sheath  of  the  clitoris 3 

"    anus     ...........  12 

"    buttocks 1 

"    thighs. 1 

"    under  lip      ..........  6 

"    ujjper  lip      .         .         .         .         .         .         .         .         .     ■    .  4 

"    labial  commissures        ........  1 

"    nostrils          ..........  2 

Both  breasts        ..........  3 

The  right  breast 1 

"    left  breast 5 

Regions  not  determined        ........  5 

Total         ....  130 

By  comparing  these  tables  with  those  upon  pages  348,  349,  it  is  seen  that 
the  seat  of  chancres  is  still  more  extensive  than  that  of  the  chancroid,  since 
it  embraces  tlie  face  and  buccal  cavity,  where  the  last-mentioned  ulcer  is 
rarely  met  with  in  practice,  but  where  the  syphilitic  virus  is  often  inocu- 
lated from  a  secondary  lesion  in  the  contact  of  mouth  with  mouth,  etc. 

Among  the  rarer  situations  of  a  chancre,  should  be  mentioned  the  walls 
of  the  pharynx,  where  a  certain  aural  specialist  of  Paris  is  said  to  have 
inoculated  several  of  his  patients  by  means  of  a  Eustachian  catheter  which 
he  neglected  to  cleanse.  A  remarkable  instance  came  under  our  observa- 
tion of  a  chancre  concealed  beneath  the  upper  eyelid,  showing  no  signs  of 
its  presence  externally,  even  upon  the  free  margin  of  the  lid.  The  })atient 
aj)[)lied  to  me  for  disease  of  the  eye,  and  on  everting  the  upper  lid  I  found 
a  superficial  excoriation  which  bore  a  striking  resemblance  to  a  chancrous 
erosion,  and  just  in  front  of  the  ear  on  the  same  side  was  an  indurated 
ganglion.  The  genital  organs  were  sound.  I  exhibited  the  case  and 
stated  my  diagnosis  to  my  class  at  the  College  of  Physicians  and  Surgeons, 
and  under  ex[)ectunt  treatment  secondary  symptoms  made  their  appearance 
after  the  usual  period  of  incul)ation.  The  man  was  a  stu])id  Irishman, 
made  his  living  by  slaughtering  .sheep,  was  married,  and  I  never  could 
obtain  any  clue  to  the  manner  in  which  he  contracted  the  disease. 

Has  the  chancre  a  period  of  incubation  ?  This  is  an  important  question, 
since  it  involves  two  others  of  great  practical  interest:  1.  AVhether  the 
fliancre  is  a  local  or  constitutional  lesion;  2.  Whether  its  abortive  treat- 
ment can  prevent  systemic  infection.  As  I  have  shown  in  another  chapter, 
the  chancre  produced  by  inoculation  of  the  secretion  of  secondary  symp- 
toms undoubtedly  has  a  period  of  incubation,  amounting  on  the  average 
to  more  than  three  weeks.  Again,  in  three  cases  of  artificial  inoculation 
of  the  secretion  of  a  chancre,  performed  by  RoUet,^  Rinecker,  and  Gi"bert, 

'  Arch.  gen.  de  med.,  avril,  1859,  p.  409. 


PERIOD    OF    INCUBATION.  447 

the  period  of  incubation  Avas  18,  25,  and  24  days  respectively.  In  clinical 
observation,  the  same  difficulties  obtain  as  have  already  been  mentioned 
with  regard  to  the  chancroid,  but  many  careful  observers  have  noticed 
the  fact  that,  as  a  general  rule,  advice  is  sought  at  a  later  period  for  a 
chancre  than  for  the  chancroid,  and  the  interval  between  contagion  and 
the  appearance  of  the  ulcer  is  represented  by  patients  as  longer  in  the 
former  than  in  the  latter.  Diday  made  minute  inquiry  of  twenty-nine 
persons  whose  chancres  were  of  recent  origin,  who  appeared  to  be  trust- 
worthy, and  certain  of  the  facts  which  they  stated,  who  had  been  exposed^ 
but  once,  and. who  had  had  no  previous  connection  for  at  least  a  month, 
and  found  that  the  average  interval  between  the  sexual  act  and  the  appear- 
ance of  the  sore  was  fourteen  days.'  M.  Chabalier,  in  an  examination  of 
ninety  cases  of  chancre,  found  an  average  period  of  incubation  of  from 
fifteen  to  eighteen  days;  and  states  that  the  chancroid,  on  the  contrary, 
is  visible  within  thirty-six  to  forty-eight  hours  after  contagion.-  M.  Clerc 
has  especially  insisted  upon  the  presence  of  incubation  as  diagnostic  of  the 
chancre,  and  has  reported  several  cases  which  were  preceded  by  a  period 
of  incubation  of  thirty  days. 

A  gentleman  of  this  city,  of  high  social  position,  whom  I  know  so  inti- 
mately tliat  I  can  vouch  for  the  truth  of  his  statements,  visited  Paris, 
unaccompanied  by  his  wife,  and,  while  under  the  influence  of  wine,  for 
the  first  time  during  fifteen  years  of  married  life  had  connection  with  a 
woman  of  the  town.  This  was  on  the  eve  of  his  return  to  America,  and 
his  subsequent  remorse  and  anxiety  were  so  great  that  on  his  voyage  home 
he  examined  himself  daily  with  the  greatest  care  to  see  if  he  had  contracted 
any  disease.  His  prepuce  was  very  short,  so  that  the  glans  was  habitu- 
ally uncovered,  and  no  lesion  was  likely  to  escape  observation,  yet  he 
found  nothing  until  the  day  of  his  arrival  home,  the  thirty-fifth  after  ex- 
posure, when  he  noticed  a  slight  excoriation  upon  the  internal  surface  of 
the  prepuce.  Pie  showed  it  to  his  family  physician,  a  "  Homoeopath," 
who  told  him  that  it  was  a  mere  abrasion  which  would  heal  in  a  few  days, 
and  that  he  might  with  safety  have  connection  with  his  wife.  As  the 
promised  cicatrization  did  not  take  place,  on  the  fourth  day  after  his 
arrival  he  applied  to  me,  and  I  found  a  superficial  chancre  with  well- 
marked  parchment  induration  and  attendant  indurated  ganglia.  Since 
then  he  and  his  wife  have  had  several  attacks  of  general  syphilis. 

Castelnau  reports  a  case  communicated  to  him  by  the  physician  of  a 
venereal  hospital,  who  was  himself  the  subject  of  tlic  observation,  in  wliicli 
a  chancre  appeared  thirty-three  days  after  an  impure  intercourse.' 

Fournier*  relates  a  number  of  cases  of  comparatively  long  incubation, 
amounting  to  28,  21,  39,  28,  21,  21,  40,  29,  23,  25,  21,  34,  28,  30,  30,  30, 
27,  35,-42,  45,  21,  42,  42,  30,  42,  35,  48,  21,  33,  40,  25,  28,  34,  28,  30, 

'  Gaz.  med.  de  Lyon,  mars  1,  1858. 

*  Tliese  de  Paris,  No.  52,  1860,  p.  Ill, 

3  Anuales  des  maladies  de  la  peau  et  de  la  syphilis,  t.  i,  p.  212. 

*  Kecherches  sur  la  incubation  de  la  syphilis,  18(J5. 


448  INITIAL    LESION    OF    SYPHILIS. 

35,  17,  30,  37,  21,  30,  70,  2i),  28,  und  30  days.  The  longest  incubation 
that  we  liave  ourselves  observed  was  50  d.ays. 

But  further  evidence  on  this  point  is  unnecessary.  There  can  be  no 
question  that  the  initial  lesion  of  syphilis,  as  of  otiier  infectious  diseases, 
possesses  a  period  of  incubation,  upon  an  average  of  froni  two  to  three 
weeks,  and  sometimes  extending  to  five,  six,  or  even,  in  rare  instances,  to 
eleven  weeks;  and  this  fact  leads  to  the  important  conclusion  that 

An  interval  of  tivo  loeeks  or  more  hettveen  the  last  exposure  and  the 
^appearance  of  a,  suspicious  sore  upon  the  genitals,  renders  it  extremely 
probable  that  the  latter  is  a  true  chancre. 

To  ascertain  its  shortest  limit  is  attended  with  more  difficulty,  since  the 
virus  is  sometimes  deposited  in  a  wound  or  abrasion  occurring  at  the  time 
of  coitus,  and,  in  consequence  of  inattention  to  clealiliness  or  other  acci- 
dental causes,  remaining  open  until  the  development  of  the  chancre,  so 
that  it  is  impossible  to  say  precis«dy  when  the  simple  is  transferred  into 
the  specific  ulcer.  The  inoculation  of  the  same  point  with  the  chancroidal 
and  sypliilitic  poisons  will  also  explain  why  in  some  instances  the  initial 
lesion  of  syphilis  appears  to  be  develo[)ed  in  some  cases  earlier  than  in 
others,  since  the  action  of  the  former  virus  commences  at  once  and  gives 
rise  to  an  ulcer  which  may  be  perceived  by  the  patient  in  the  course  of 
two  or  three  days,  and  which  masks  the  later  development  of  the  chancre. 

When  inquiring  into  the  incubation  of  a  venereal  ulcer,  the  surgeon 
must  be  on  his  guard.  A  patient  applies  to  him  with  a  sore  and  says  he 
w^as  exposed  three  days  before.  The  careless  surgeon  chimes  in  with  the 
idea  of  tlie  patient  that  the  sore  was  thus  recently  contracted,  and,  on  the 
ground  that  there  has  been  no  period  of  incubation,  pronounces  it  a  chan- 
croid, forgetting  to  ask  the  patient  wdien  he  was  exposed  before  this  lo?t 
time  I  Such  inquiry  will  often  elicit  the  fact  that  the  previous  exposures 
have  been  frequent  and  closely  approximated,  and  that  at  which  of  them 
the  inoculation  took  place  is  a  "  conundrum."  If  the  sore  prove  to  be  a 
true  chancre,  it  was  certainly  not  at  the  last  one — three  days  before — that 
the  mischief  was  done. 

Symptoms. — The  following  table,  prepared  by  M.  Bassereau,^  of  the 
chancres  which  preceded  170  cases  of  syphilitic  erythema,  will  indicate 
the  various  forms  which  a  chancre  may  assume,  and  afford  some  idea  of 
the  comparative  frequency  of  these  forms  in  the  milder  cases  of  the  disease, 
of  which  the  more  severe  instances  exhibit  a  larger  proportion  of  excavated 
ulcers  : — 

Superficial  erosions         ...........     146 

Circumscribed  ulcers,  with  abrupt  edges,  involving  the  wliole  thickness  of 

the  skin  or  mucous  membrane         ........       14 

Circumscribed  x^hagedenic  ulcers,  witli  a  pultaceous  floor,  involving  the  tis- 
sues a  short  distance  beyond  the  skin  or  mucous  membrane  ...       10 

Total,         170 
'  Op.  cit.  p.  140. 


SYMPTOMS.  449 

It  appears  from  this  table  that  the  chancre  has  no  exclusive  form,  but 
that  it  most  frequently  assumes  one  which  differs  widely  from  the  chancre 
type  as  formerly  described  by  many  authors.  The  frequency  of  the 
superficial  form  of  chancre  excited  my  attention  several  years  before  I  had 
met  with  any  description  of  it  in  books,  and  the  first  cases  which  came 
under  my  notice  were  mistaken  for  mere  abrasions  until  the  appearance  of 
secondary  symptoms  corrected  the  diagnosis. 

The  superficial  form  of  chancre  is  most  marked  on  the  internal  surface 
of  the  prepuce,  by  which  it  is  protected  from  the  air  and  friction,  and 
kept  free  from  scabs  ;  and  it  is  in  this  situation  that  it  is  most  frequently 
met  with.  It  has  generally  a  circular  or  ovoid,  but  sometimes  irreo-ular, 
outline.  Its  floor  is  but  slightly,  if  at  all  excavated,  and  occasionally  is 
even  elevated  above  the  surrounding  integument  by  the  subjacent  indura- 
tion. Its  surface  is  smooth,  often  looking  as  if  polished,  destitute  of  the 
consistent  and  adherent  exudation  of  the  chancroid,  and  of  a  red  or  gray- 
ish color  ;  or,  at  times,  it  is  dark  or  even  black,  owing  to  molecular  o-an- 
grene. 

Moreover,  there  is  a  frequent  feature  of  the  chancrous  erosion  which  I 
have  often  observed,  and  which  Avas  first  described  by  my  friend,  M.  Clerc, 
of  Paris,  wMio  gave  several  admirable  representations  of  it  in  his  Traite 
pratique  des  maladies  veneriennes.  I  refer  to  a  "kind  of  false  membrane, 
presenting  some  resemblance  to  the  diphtheritic  patches  which  characterize 
certain  forms  of  syphilitic  symptoms  occupying  the  mucous  membranes." 
It  is  entirely  distinct  in  its  appearance  from  the  membrane  covering  a  chan- 
croid, but  the  difference  is  better  seen  than  described.  I  can  only  say, 
that  it  usually  occupies  only  the  centre  of  the  chancre,  that  its  edges  shade 
off  into  the  reddish  circumference,  that  it  is  of  a  translucent,  slightly 
greenish,  and  pultaceous  appearance,  unlike  the  dull  or  yellowish-gray 
membrane  which  covers  the  whole  surface  of  a  chancroid.  M.  Clerc  be- 
lieves that  this  diphtheritic  layer  is  a  consta^it  feature  of  a  chancre  durin^ 
the  early  stage  (first  two  weeks)  of  its  existence.  I  cannot  regard  its  pre- 
sence as  thus  invariable,  but  it  is  certainly  very  frequent,  and  is  well 
worthy  of  careful  ol)servation. 

The  secretion  of  this  form  is  a  clear  serum — free  from  pus-globules, 
unless  the  sore  has  been  irritated — which  may  often  be  seen  issuing  from 
minute  pores,  after  the  previous  moisture  has  been  wiped  away.  It  has 
no  surrounding  areola,  and  leaves  no  cicatrix  to  mark  its  site.  Barely 
one-third  of  the  chancres  in  Bassereau's  170  cases,  left  any  visible  traces 
aside  from  induration.  When  situated  upon  the  external  integument,  as 
the  sheath  of  the  penis — where  most  venereal  ulcers  are  chancres — and 
exposed  to  the  air,  it  becomes  covered  with  scabs,  which  give  it  the 
appearrwice  of  a  pustule  of  ectliyma,  or  a  patch  of  scaly  erujition,  and 
which  may  readily  lead  to  an  error  in  diagnosis.  The  cliaracters  of  the 
chancrous  erosion  are  also  modified  by  the  application  of  irritants,  or  by  a 
want  of  cleanliness  ;  its  secretion  may  become  purulent,  and  its  surface 
resemble  tliat  of  the  chancroid  ;  but  its  normal  ;ippearance  may  be  restored 
by  applying  a  water-dressing  for  a  few  days. 
29 


450  INITIAL    LESION    OF    SYPHILIS. 

Frequent  as  is  the  chancrous  erosion,  it  must  not  be  regarded  as  the 
exclusive  form  of  clinncre.  Diday  believes  that  it  is  due  to  inoculation 
from  a  secondary,  and  that  the  excavated  chancre  is  produced  by  inocula- 
tion from  a  primary  lesion,  but  this  distinction  will  not  hold.  Between  this 
form  and  the  indurated  excavated  ulcer,  known  as  the  Ilunterian  chancre — 
which  was  so  long  and  so  erroneously  supposed  to  be  the  especial  harbinger 
of  general  syphilis — there  may  exist  many  gradations  which  it  is  unneces- 
sary to  describe  in  detail.  Ulcerative  action  may  go  beyond  this  point, 
and  terminate  in  phageda^na ;  but,  generally,  it  is  limited  by  the  plastic 
inflammation  of  the  surrounding  tissues,  as  is  evident  from  an  examina- 
tion of  the  edges  of  nearly  all  the  forms  of  chancre,  which  are  sloping, 
somewhat  prominent  and  adherent,  unlike  the  abrupt  and  detached  mar- 
gins of  the  chancroid.  If  phagedaMia  occur,  the  destructive  process  is 
usually  limited  to  the  induration  (neoplasm),  and,  on  the  final  healing  of 
the  ulcer,  it  is  sur[)rising  to  see  how  little  mischief  has  been  done  to  the 
normal  tissues. 

3Iultiph  Herpetlforin  Chancres Under  this  title   Dubuc  first  called 

attention  to  a  variety  of  syphilitic  cliancre,  liable  to  be  mistaken  for  herpes. 
These  chancres  have  a  diameter  of  a  line  or  less  ;  they  look  like  small 
round  excoriations,  of  a  deep-red,  sometimes  coppery  hue,  which  bleed 
readily  and  have  very  slight  induration  of  their  bases.  The  induration 
often  increases  at  a  later  period.  From  five  to  fourteen  chancres  may  be 
observed  upon  the  jjrepuce  or  glans.  In  their  first  stage  the  diagnosis  is 
difiicult ;  but  the  absence  of  itching  and  burning,  their  dark  color  and 
their  chronicity  are  points  which  aid  in  distinguishing  them  from  herpes. 
Another  important  feature  is  that  their  surface  is  very  smooth  and  shining. 
Moreover,  induration  of  the  inguinal  ganglia  is  soon  developed.  Tlie 
duration  of  these  herpetic  chancres,  is,  according  to  Dubuc,  a  month  or 
six  weeks.  In  exceptional  cases,  in  which  the  chancres  are  not  close 
together,  they  remain  separate  during  their  whole  course.  In  the  majority 
of  cases  they  are  closely  groujjcd,  and  after  remaining  for  several  weeks 
in  the  herpetic  form,  they  unite  and  form  a  single  chancre. 

Anomalous  Appearance  of  the  Initial  Lesion  of  Syphilis The  chancre 

is  subject  to  various  modifications.  One  of  the  rarest  is  that  described  by 
Dr.  P.  A.  Morrow'  as  '•'■  diphtheroid  of  the  ylans."  In  the  case  which  he  had 
under  his  care  and  which  we  had  the  op[)ortunity  of  observing,  '•  the  anterior 
four-fifths  of  the  glans  penis  was  covered  with  a  glistening  grayish-white 
coaling  of  a  leathery  consistence,  simulating  in  all  its  physical  character- 
istics a  diiihtheritic  exudation.  This  coating  was  of  uniform  thickness, 
raised  about  two  lines  above  the  licalthy  mucous  membrane,  and  covered 
tlie  entire  surface  of  the  ghms,  except  a  narrow  zone  embracing  the 
corona. 

"The  edges  of  the  coating  were  abruptly  raised,  and  the  line  of  demar- 

'  On  a  rare  form  of  initial  lesion,  Diphtheroid  of  tlie  glans  penis  :  Report  of  a 
case  with  renaarks.  P.  A.  Morrow,  M.D.  Arch.  Deruiat.,  N.  Y.,  1876,  vol.  ii, 
p.  383. 


INDURATION.  451 

cation  between  its  border  and  the  healthy  tissue  was  distinct  and  unmasked 
by  any  inflammatory  areola.  This  appearance  was  suggestive  of  a  white 
membranous  hood  drawn  over  the  head  of  the  penis,  with  a  slit-like  open- 
ing for  the  meatus  in  front.  So  evenly  and  smoothly  was  it  moulded  over 
the  glans  that  the  contour  was  perfectly  preserved.  A  sensation  of  a 
smooth  greasy  feel  was  communicated  to  the  finger  passed  over  the  surface. 
There  was  absolutely  no  erosion — its  epithelial  coat  seemed  to  be  con- 
tinuous with  that  of  the  healthy  mucous  membrane,  wdiich  limited  its 
circumferential  border  above.  Its  base  was  supple,  with  no  trace  of  indu- 
ration. Its  surface  was  moist  and  glistening,  with  no  appreciable  secretion. 
It  was  intimately  adherent,  and  could  not  be  detached  from  the  tissues 
which  supported  it  without  leaving  a  bleeding  base."  It  was  painless  and 
indolent ;  it  appeared  several  weeks  after  coitus,  and  was  followed  by 
secondary  symptoms. 

In  three  cases  which  we  have  seen  at  the  New  York  Dispensary,  the 
lesion  was  developed  in  round  or  oval  [  atches,  less  than  an  inch  in  dia- 
meter. In  one  case  the  patch  was  continuous  with  an  indurated  nodule. 
The  lesion  disappeared  slowly,  leaving  the  parts  normal  or  slightly  pig- 
mented. For  reasons  given  in  our  published  reply'  to  Dr.  Morrow,,  we 
do  not  consider  this  a  diphtheroid  condition  of  the  initial  lesion.  We 
regard  it  rather  as  a  form  of  scaling  or  dry  chancre,  the  '■'■  papule  seche"  of 
Lancereaux.  In  this  lesion  the  syphilitic  cells  are  developed  in  the  super- 
ficial tissues  of  the  glans,  which  are  thereby  thickened  and  assume  a 
leathery  appearance.  The  whitish  color  is  probably  due  to  the  close 
packing  of  the  cells. 

Infecting  Balano-posthitis Under  this  title  Mauriac  has  described  a 

form  of  initial  lesion  which  is  liable  to  be  mistaken  for  simple  balano- 
posthitis.  In  this  lesion  the  mucous  membrane  of  the  prepuce  is  thick- 
ened, has  a  deep  red  color,  and  is  slightly  excoriated  either  partially  or 
completely.  Tiie  glans  may  be  superficially  thickened,  and  is  generally 
hypera^mic  and  eroded.  Retraction  of  the  i)repuce,  which  may  be  some- 
wliat  difficult  or  quite  impossible,  best  displays  its  infiltrated  condition. 
Tlie  induration  may  be  evenly  distributed  or  irregular;  its  localization 
may  be  marked  in  the  fossa  near  the  fnenum,  in  which  case  there  exists 
merely  an  indurated  nodule.  The  course  of  the  lesion  is  chronic,  but  it 
yields  readily  to  internal  treatment.  The  lesion  consists  of  an  infiltration 
of  the  subnuicous  tissue  with  hyperannia ;  in  other  words,  it  is  a  combina- 
tion of  cell-infiltration  and  litu'd  oedema. 

Induration  was  recognized  at  a  very  early  [)eriod  in  the  history  of  syphilis, 
first  by  Torella,  in   1497,  by  John  de  Vigo,^  Gabriel   Fallopius,"  Leonard 

'  XotHH  on  a  rare  ai)pearaTice  prosentcd  by  the  initial  losiou  of  syphilis.  R.  W. 
Taylor,  M.D.     Arch.  Derinat.,  N.  Y..  1877,  vol.  iii,.  p.  5. 

*  "Nam  ejus  origo  in  partibus  gt^nitalilius,  videlicet  in  vulva  in  mulicribus  et 
in  virga  in  homiinl)us,  semper,  fuit  cum  pustulis  parvis,  interdum  lividi  coloris, 
aliquando  iiigri,  non  nuiiquam  sulialbidi,  cum  callositate  eas  circuiudante."  (Jou.v 
UE  Vico,  Pritcticd  cojiiosa  in  Ai-te  Cliiruryica,  etc.     Ilom«,  1514,  lib.  v.) 

*  Tractatus  de  Morbo  Gallico,  Patavium,  15G4. 


452  INITIAL    LESION    OF    SYPHILIS. 

Botal/  and  Ambrose  Parc,^  as  a  prominent  symptom  of  the  sore  which 
precedes  general  syphilis;  nearly  forgotten  by  subsequent  writers,  though 
occasionally  mentioned,  as  by  Nicholas  Blegny,''  it  again  assumed  im- 
portance in  modern  times  fi-om  the  teachings  of  Hunter,*  Bell,"  and 
especially  Ricord,  and  is  now  justly  regarded  as  the  most  characteristic 
feature  of  a  chancre,  when  seated  upon  a  person  exempt  from  previous 
syphilitic  taint. 

The  induration  of  a  chancre  is  a  peculiar  hardness  of  the  tissues  around 
and  beneath  the  sore.  Simple  inflammation  may  occasion  an  effusion  of 
plastic  material  and  consequent  engorgement  about  any  sore ;  but  specific 
induration  is  of  an  entirely  distinct  character.  The  latter  is  formed,  as 
the  French  say,  "  a  froid,''^  that  is,  without  inflammatory  action ;  the 
deposit  takes  place  in  the  absence  of  all  the  symptoms  of  inflammation, 
"pain,  heat,  redness,  and  swelling;"  and  so  silently,  so  insidiously,  that 
the  patient  is  often  ignorant  of  its  presence,  or  discovers  it  only  by  acci- 
dent. No  event  is  more  common  than  for  a  surgeon  to  be  consulted  by  a 
man  who  states  that  he  had  a  sore  a  few  weeks  ago,  "  which  did  not 
amount  to  much;"  he  "  burnt  it  with  caustic  and  it  healed  up;"  but  he 
hag  recently  found  that  it  left  a  "lump"  behind  it.  This  "lump"  is 
specific  induration  and  denotes  that  the  constitution  is  infected.  A  gentle- 
man applied  to  me  for  phimosis — neither  congenital  nor  inflammatory — 
which  occasioned  no  inconvenience  except  an  inability  to  retract  the 
prepuce.  He  was  not  aware  that  he  had  had  any  venereal  trouble,  but, 
on  examination  of  the  parts,  a  mass  of  induration  as  large  as  an  almond 
was  perceptible  to  the  touch  and  even  to  the  sight — so  great  were  its  dimen- 
sions— situated  about  the  furrow  at  the  base  of  the  glans.  The  phimosis 
was  simply  due  to  the  mechanical  obstruction  presented  by  the  induration 
to  the  retraction  of  the  [)repuce,  and  this  difficulty  alone  induced  him  to 
seek  advice.  Frequently,  also,  patients  ap[)ly  to  a  surgeon  for  treatment 
for  general  syphilis,  and  honestly  declare  that  they  have  never  had  a 
chancre,  though  the  previous  existence  of  such,  and  even  its  very  site,  are 
unmistakably  indicated  by  the  remaining  induration. 

Again,  specific  induration  and  inflammatory  engorgement  differ  in  their 
objective  symptoms.  The  boundaries  of  the  former  are  clearly  defined, 
while  the  extent  of  the  latter  cannot  be  limited  with  nicety ;  the  one  ter- 
minates abruptly,  the  other  shades  gradually  into  the  normal  suppleness  of 
the  part ;  the  first  is  freely  movable  upon,  the  second  adherent  to,  the 
tissues  beneath.  The  difference  in  the  sensations  they  impart  to  the  fingers 
is  still  greater;  specific  induration  is  so  firm,  hard,  and  resistant,  that  it 

'  Luis  Venerec-e  Curand<e  Ratio,  Paris,  1563. 

2  "  S'il  y  a  ulcere  a  la  verge  et  s'il  demeure  duret^  au  lieu,  telle  chose  infallible- 
raent  montre  le  malade  avoir  la  varole."  (Fare's  works,  first  published  at  Paris, 
1575,  Book  19th.) 

^  L'art  de  gu^rir  les  maladies  ven6riennes,  etc.,  Paris,  1673. 

*  Ricord  and  Hunter  on  Venereal,  2d  Am.  edition,  Phil.,  1859,  p.  286. 

5  Treatise  on  Gonorrhoea  Virulenta  and  Li  ^  Venerea,  London,  1793,  vol.  ii,  p. 
19. 


INDURATION.  453 

is  often  compared  to  a  "  split-pea"'  or  mass  of  cartilage :  the  softer  and 
dougliy  feel  of  common  inflammatory  engorgement  requires  no  description. 
It  is  hardly  necessary  to  say  that  there  is  no  incompatibility  between  these 
two  pathological  conditions  which  can  prevent  their  coexistence,  and 
hence  arises,  in  some  few  cases,  a  difficulty  of  diagnosis.  The  effect  of 
sim[)le  inflammation,  however,  subsides  in  a  few  days,  or  in  a  week  or  two 
at  farthest,  and  lays  bare  the  specific  induration,  which  may,  for  a  time, 
have  been  buried  beneath  it ;  and  under  all  circumstances  reference  may 
be  made  to  the  neigliboring  ganglia,  the  induration  of  which  is  equally 
constant  and  significative  with  that  of  the  chancre. 

In  the  masses  of  induration  of  considerable  size  to  which  the  above 
description  chiefly  refers,  the  adventitious  deposit  occupies  the  skin  or 
mucous  membrane  bordering  upon  the  edges  of  the  sore,  and  also  the 
cellular  tissue  beneath  it.  There  is  another  but  less  common  form  of 
induration  in  which  the  deposit  is  confined  to  the  mucous  membrane  alone, 
and  does  not  involve  the  cellular  tissue  beneath.  It  most  frequently  occurs 
in  connection  with  the  superficial  chancre,  and  is  called  the  "  parchment- 
induration"  because  it  imparts  to  the  fingers  a  sensation  as  if  the  erosion 
rested  upon  a  thin  layer  of  that  material.  Readily  perceived  in  most 
cases,  in  others  it  may  escape  notice,  especially  to  one  not  familiar  with  it. 

The  situation  of  the  chancre  influences  to  a  certain  extent  the  degree 
of  development  of  the  induration  ;  which,  for  instance,  is  generally  but 
slightly  marked  and  of  tlie  parchment  variety  in  certain  regions,  as  at 
the  margin  of  the  anus ;  while,  on  the  contrary,  it  is  fully  developed 
in  the  furrow  at  the  base  of  the  glans  and  upon  the  upper  lips.  Some 
authorities  have  gone  so  far  as  to  maintain  that  induration  is  entirely 
dependent  upon  the  seat  of  tlie  sore,  and  have  instanced  the  uniformity 
with  which  all  venereal  ulcers  upon  the  lips  are  indurated,  in  proof;  but, 
as  before  stated,  tliis  objection  to  a  duality  of  venereal  poisons  has  been 
effectually  exploded  by  recent  experimental  inoculations,  in  which  chan- 
croids with  a  perfectly  soft  base  have  been  developed  upon  the  region  in 
question. 

Ricord  believes  that  the  development  of  induration  corresponds  with 
the  supply  of  lymphatic  vessels ;  that  the  former  is  most  marked  where 
the  latter  are  most  abundant;  and  that  the  induration  consists  in  an  inflam- 
mation of  the  capillary  absorbents  with  effusion  into  the  intervening 
tissue.^  The  investigations,  however,  of  Auspitz  and  Unna,  to  be  men- 
tioned presently,  show  a  remarkable  immunity  of  tlie  lym[)hatics  in  the 
indurated  mass.     Thus  it  is  seen  in  Figs.  117  and  118  (pp.  4G4  and  405) 


'  Benjamin  Bell  usually  has  the  credit  of  the  comparison  of  induration  to  a  split- 
pea,  but  reference  to  liis  work  shows  that  he  uses  the  term  as  indicative  of  the  size 
of  a  chancre,  and  not  of  the  consistency  of  its  base.  He  says  :  "A  real  venereal 
chancre  is  seldom  so  large  as  tlie  base  of  a  split-pea,  and  the  edges  of  the  sore  are 
elevated,  somewhat  hard,  and  painful."     Op.  cit.,  vol.  i,  p.  19. 

*  Le9ons  sur  le  cliancre,  p.  86. 


454  INITIAL    LESION    OF    SYPHILIS. 

that,  notwithstanding  the  arteries  and  veins  are  partially  or  wholly  ob- 
literated, the  walls  of  the  lym[)hatics  are  unaffected  and  their  lumen 
unobstructed.  Fibrillary  hypertrophy  of  the  connective  tissue  of  the 
adventitia  of  the  bloodvessels,  round-cell  infiltration,  disappearance  of  the 
lymph  spaces,  and  similar  changes  in  the  perivascular  tissues,  are  the 
essential  changes  to  be  found  in  chancrous  induration. 

Kicord  has  endeavored  to  determine  the  limits  of  time  within  which 
induration  may  take  place.  He  states  that  it  occurs  most  frequently 
during  the  first  or  second  week  after  contagion  ;  never  before  the  third 
day,  nor  after  the  third  week  ;  that,  consequently,  if  a  sore  is  to  be  indu- 
rated at  all,  it  will  be  so  by  the  twenty-first  day  after  the  sexual  act  in 
which  it  originated.  It  is  with  great  reluctance  and  hesitation  that  I 
dissent  from  so  accurate  an  observer,  but  believing  as  I  do  in  the  incu- 
bation of  the  chancre,  I  cannot  but  think  that  this  subject  requires  re- 
newed investigation  with  the  additional  light  we  now  possess.  I  believe  it 
would  be  nearer  the  truth  to  substitute  the  words  "  after  the  appearance  of 
the  chancre"  in  place  of  "  after  contagion."  Taking  the  former  as  the  start- 
ing point,  there  can  be  no  question  but  that  induration  occurs  within  a  very 
few  days;  I  have  almost  inv^ariably  met  with  it  on  the  earliest  appearance 
of  the  chancre,  or  during  the  first  week,  and  should  not  hesitate  to  regard 
its  absence,  at  the  termination  of  three  weeks,  both  in  the  sore  itself  and 
in  the  neighboring  ganglia,  as  indicative  that  the  patient  was  safe  from 
constitutional  infection. 

Sigmund,^  of  Vienna,  gives  the  following  table  of  the  dates  after  conta- 
gion at  which  induration  was  first  detected  in  '2(]\  cases  of  chanoi'es  : — 

On  the  9tli  day  in 

"       10th     '"  

"      14th      "  

"      17th      "  

"      19th      "  

"      21st       "  

Mr.  Babington,  the  English  editor  of  Hunter  on  Venereal,  advanced 
the  opinion  that  induration  may  take  place  before  the  appearance  of  the 
chancre,  and  this  fact,  which  was  for  a  time  denied,  has  of  late  years  been 
proved  to  be  true,  both  by  the  results  of  artificial  inoculation,  and  by  some 
instances  met  with  in  clinical  observation ;  indeed,  in  a  few  rare  cases 
the  initial  lesion  of  syphilis  has  been  found  to  consist  only  of  an  indura- 
tion, without  any  ulceration  Avhatever.  After  all,  if  it  be  admitted  that 
all  possible  mischief  is  accomplished  long  before  the  chancre  first  appears, 
the  exact  date  of  the  evolution  of  the  induration  possesses  less  practical 
im|)ortance  than  it  assumed  under  the  supposition  that  it  marked  the 
boundary  line  between  "local"  and  constitutional  syphilis. 

Specific  induration  usually  remains  for  a  long  time  after  the  cicatrization 

«  British  and  For.  Mcd.-Chir.  Rev.,  Jan.,  1857,  p.  200  ;  from  the  Wien  Wochen- 
schrift.  No.  18. 


71 

cases 

84 

7t> 

15 

12 

3 

INDURATION.  455 

of  tlie  chancre,  and,  unless  dissipated  by  treatment,  may,  in  most  cases, 
be  felt  for  at  least  two  or  three  months,  and  often  longer.  Some  statistics 
collected  by  M.  Puche  show  that  its  persistency  becomes  rarer  after  the 
third  month,  and  is  quite  exceptional  after  the  eighth,  though  this  surgeon 
reports  thirteen  cases  in  which  it  was  perceptible  from  390  to  20G2  days 
after  contagion  ;  in  nine  of  the  thirteen,  the  induration  occupied  the  furrow 
at  the  base  of  the  glans,  a  favorite  seat  for  its  full  development  and  long 
persistency.  M.  Puche  met  with  still  another  instance  in  which  induration 
persisted  for  nine  years.  I  have  met  with  several  cases  of  two  and  three 
years'  duration,  and  Ricord  with  one  of  thirty  years.  It  follows  from  tlie 
above  data  that  induration  is  an  early  symptom  of  syphilis,  and  that  the 
time  within  which  its  presence  or  absence  is  of  diagnostic  value  is  limited, 
though  variable  in  different  cases. 

Induration  is  sometimes  much  shorter  lived;  the  parchment  form  espe- 
cially, may  entirely  disappear  before  the  chancre  heals,  and  the  cicatrix 
present  as  soft  a  base  as  the  chancroid.  This  form  of  induration  is,  how- 
ever, in  many  instances,  as  durable  as  any  other. 

As  the  process  of  absorption  goes  on,  the  indurated  mass  becomes  less 
fii"m  and  resistent,  and  gradually  softens  until  it  can  finally  no  longer  be 
detected.  In  other  instances,  after  partial  absorption  has  taken  place,  the 
induration  suddenly  resumes  its  earlier  dimensions,  and  this  is  most  likely 
to  occur  upon  the  first  appearance  of  secondary  symptoms,  or  at  a  subse- 
quent relapse  of  the  same. 

Under  the  name  of  '•'■indurations  de  voisinage"  Fournier^  describes 
masses  of  induration,  contemporaneous  with  the  chancre,  but  occurring 
secondarily  at  a  short  distance  from  it.  I  have  seen  several  cases  of  the 
kind.  The  induration  is  probably  seated  in  the  tunics  of  the  bloodvessels 
emanating  from  the  seat  of  the  chancre,  and  in  the  surrounding  cellular 
tissue.  Although  the  surface  of  such  indurations  usually  remains  intact, 
it  may  take  on  ulceration  in  the  manner  hereafter  described. 

Relapsinff  Induration The  genital  organs  may  at  any  time  in  the 

course  of  sypliilis  be  the  seat  of  indurated  nodides  whicii  are  liable  to  be 
mistaken  for  primary  lesions. 

They  are  of  two  kinds — the  superficial  and  deep.  The  superficial  indu- 
ration is  in  every  respect  like  a  true  cliancre,  consisting  of  a  localized 
infiltration,  somewhat  elevated,  having  a  smooth  exulcerated  surface, 
which  secretes  a  scanty  mucous  fluid.  It  generally  appears  upon  the 
mucous  layer  of  the  prejiuce  or  upon  the  glans  in  the  form  of  a  small 
papule.  It  runs  an  indolent  course,  but  may  reach  quite  a  large  size.  It 
is  usually  accompanied  by  enlargement  of  the  inguinal  ganglia.  It  some- 
times appears  exactly  on  the  former  seat  of  a  primary  lesion,  and  is  gene- 
rally solitary. 

The  deep  relapsing  induration  occurs  in  the  submucous  connective  tissue 
of  the  pre[)uce  and  of  the  laljia  majora.     It  consists  of  a  sharply-defined 

'  Etude  clinique  sur  riiiduration  .syi)liiliti(iue  primitive,  Areli.  gen.  de  m^d., 
nov.,  1807. 


456  INITIAL    LESION    OF    SYPHILIS. 

nodule  of  cartilaginous  hardness,  freely  movable  and  generally  not  adherent 
to  the  mucous  membrane.  Its  growth  is  rapid,  and  it  sometimes  reaches 
the  size  of  a  nutmeg.  There  may  be  several  of  these  tumors,  and  we  have 
seen  five  in  one  case.  The  lesion  may  remain  inactive  for  a  long  time, 
causing  no  pain  but  giving  some  inconvenience  in  coitus.  In  some  cases 
it  contracts  adhesions  with  the  surrounding  soft  {)arts;  exceptionally,  it 
undergoes  necrosis  and  forms  a  deep  ulcer,  which  is  difficult  of  cure.  In 
women  the  infiltration  is  often  very  large,  involving  perhaps  the  whole  . 
labium.  The  induration  is  very  marked  and  often  persists  for  years.  In 
rare  cases  the  labia  minora  are  involved.  There  is  usually  no  enlargement 
of  the  inguinal  ganglia  with  the  deep  induration,  either  in  men  or  in  women. 

These  indurations  may  occur  as  early  as  the  first  and  as  late  as  the  tenth 
year  of  syphilis.  They  are  amenable  to  early  treatment,  but  are  more 
obstinate  with  age.  They  have  been  known  to  undergo  spontaneous  invo- 
lution, and  to  relapse  after  complete  cure.  It  is  important  to  distinguish 
them  from  primary  lesions  of  syphilis.  Many  of  the  reported  cases  of 
reinfection  have  no  doubt  been  in  reality  examples  of  relapsing  induration. 

Secretion The  secretion  from  a  chancre  is  much  less  copious  than  that 

from  the  chancroid  and  is  chiefly  serous.  This  difference  is  especially 
evident  in  the  superficial  erosion,  but  is  also  perceptible  in  the  excavated 
forms,  the  discharge  from  which  is  less  free  and  purulent  than  in  the 
chancroid. 

Numerous  ex[)eriments  show  that  the  immunity  conferred  by  one  attack 
of  syphilis  extends  in  most  cases  even  to  the  initiatory  sore.  This  fact 
was  first  announced  by  M.  Clerc  in  1855.  Fournier  inoculated  the  dis- 
charge of  ninety-nine  chancres  upon  the  patients  themselves,  and  succeeded 
in  but  one,  in  whom  the  experiment  was  performed  within  a  very  shwt 
period  after  contagion.  M.  Puche  states  as  the  result  of  his  own  experi-  * 
ments  that  auto-inoculation  of  the  chancre  is  successful  in  only  two  per 
cent.  Poisson  obtained  like  results  in  fifty-two  cases,^  and  Laroyenne  was 
unsuccessful  in  every  one  of  nineteen.^  Do  not  these  facts  tend  to  show 
that  the  chancre  is  from  the  very  first  a  constitutional  lesion  ?  Their  bear- 
ing upon  the  use  of  artificial  inoculation  as  a  means  of  diagnosis  is  evident ; 
failure  favoring  the  supposition  that  the  sore  is  a  chancre. 

AVhenever  auto-inoculation  has  proved  successful,  it  has  been  with  virus 
taken  from  the  sore  at  a  very  early  period  of  its  existence,  or  from  one 
which  has  been  irritated  and  its  secretion  rendered  purident,  and  in  the 
latter  case,  the  resulting  sore  is  not  a  chancre  but  a  chancroid.  (See  In- 
troduction.) In  the  same  manner  vaccine  lymph  may  be  successfully 
reinocnlatod  within  a  day  or  two  after  the  first  appearance  of  the  future 
pustule,  while  if  the  attempt  be  deferred  until  its  full  development,  it  will 
fail.  Hence  we  infer,  that  although  absorption  is  instantaneous  and  gene- 
ral infection  is  inevitable  from  the  first,  yet  that  time  is  requisite  to  bring 
the  system  fully  under  the  influence  of  the  virus. 

'  Lp^ons  sxir  le  cliancro,  p.  274. 

2  Anmiaire  de  la  sypli.  ut  d.  inal.  do  la  poaii,  Paris,  annee  1858,  p.  241. 


DURATION    AND    TERMINATION.  457 

Mr.  Henry  Lee,  of  London,  as  early  as  185G,  also  called  attention  to 
the  difficulty  of  inoculating  chancres,  or  "  syphilitic  sores  affected  with 
specific  adhesive  inflammation,"  upon  the  persons  bearing  them.^  This 
surgeon  afterwards  maintained  that  if  a  chancre — the  discharge  from 
which,  under  ordinary  circumstances,  is  destitute  of  pus-globules — be  irri- 
tated, as  by  the  application  of  a  blister  or  ung.  sabinae,  until  its  secretion 
becomes  purulent,  it  is  susceptible  of  inoculation.^  This  statement  was 
confirmed  by  Prof.  Boeck  and  other  advocates  of  "  syphilization." 

The  difficulty  of  inoculating  tlie  secretion  of  a  chancre  is  equally  as 
gi'eat  upon  a  person  who  has  arrived  at  the  stage  of  secondary  syphilis  as 
upon  one  who  has  but  recently  been  infected. 

Duration The   chanci-e,  as   a  general   rule,  is   of  somewhat  shorter 

duration  than  the  chancroid,  but  often  remains  until  after  the  appearance 
of  secondary  symptoms — a  remark  which  I  should  not  think  it  necessary 
to  make  had  I  not  met  with  persons  who  supposed  that  primary  syphilis 
must  terminate  before  secondary  commenced !  Of  97  cases  observed  by 
Bassereau,  in  which  no  treatment  had  been  employed,  syphilitic  eiythema, 
one  of  the  earliest  general  symptoms,  occurred  in  bH  before,  in  18  during, 
and  in  21  after  the  cicatrization  of  the  chancre. 

Termination As  previously  stated,  most  chancres  are  not  attended  by 

any  loss  of  substance,  and  consequently  leave  no  cicatrix. 

A  chancre  situated  upon  the  external  integument,  as  the  sheath  of  the 
penis,  often  leaves  a  peculiar  discoloration  of  the  skin  of  a  sombre  brown 
or  brownish-red  color,  whicli  is  never  seen  after  the  chancroid;  in  time 
its  dark  hue  fades  into  a  white.  An  instance  of  this  kind  is  figured  by 
Ricord  in  his  Iconographie  des  maladies  venerieyines,  pi.  xviii. 

A  chancre  may  have  entirely  liealed,  leaving  an  induration  in  its  site, 
and  the  latter  again  take  on  ulceration,  commencing  either  upon  its  sur- 
face or  in  the  centre  of  the  mass,  and  form  a  sore  precisely  similar  in 
every  resi)ect  to  the  original  chancre.  In  this  case,  the  secretion  is  just 
as  infectious  as  that  of  the  first  ulceration. 

Moreover — and  this  is  an  important  point — I  have  known  this  second 
ulceration  to  take  on  phagedenic  action,  which,  under  these  circumstances, 
requires  the  active  use  of  mercury  to  arrest  it,  although  the  destructive 
nature  of  the  process  and  possibly  the  recent  administration  of  this  mineral 
would  seem  to  demand  a  contrary  course.  I  have  met  with  several  in- 
stances of  this  kind,  in  which  tiie  phagediena  tlireatened  to  destroy  the 
glans  or  penis,  and  only  yielded  to  the  timely  administration  of  mercury. 

Ricord  first  called  attention  to  the  fact,  which  has  since  been  verified 
by  many  observers,  that  a  chancre  during  the  reparative  period  may  be 
transformed  into  a  mucous  patch,  and  thus  a  primary  be  changed  into  a 
secondary  lesion.  This  transformation  may  take  place  upon  any  part  of 
the  body,  whether  of  skin  or  mucous  membrane,  but  more  frequently  upon 
the  latter,  especially  when  habitually  in  contact  witli  an  opposed  surface, 

'   Brit,  and  For.  M.  Chir.  Rev.,  London,  Oct.  185G.        «  Ibi.l.  for  Ai-ril,  1859. 


458  INITIAL    LESION    OF    SYPHILIS. 

whereby  heat  and  moisture  are  maintained  ;  as,  for  instance,  upon  the 
internal  surface  of  the  prepuce  and  labia  majora,  and  upon  the  lips  and 
tongue.  Davasse  and  Deville  have  carefully  studied  the  progressive 
clianges  by  which  this  process  is  accomplished.^  The  surface  of  the 
chancre  loses  its  grayish  aspect  and  fills  up  v/ith  florid  granulations,  com- 
mencing at  the  circumference  as  in  the  ordinary  period  of  repair  ;  but  just 
as  these  changes  are  reaching  the  centre  of  the  sore,  a  narrow  white 
border  of  plastic  material  appears  around  its  margin,  and  extending 
towards  the  centre,  finally  covers  it  with  the  membranous  pellicle  which 
is  characteristic  of  a  mucous  patch.  If  the  patient  does  not  come  under 
observation  until  these  changes  have  been  effected,  the  initial  lesion  of  his 
disease  may  be  supposed  to  be  a  mucous  jiatch  instead  of  a  chancre. 

Number  of  Chancres Unlike  the  chancroid,  the  chancre  is  rarely  met 

with  in  groups  of  two  or  more  upon  the  same  subject.  Of  556  patients 
under  the  observation  of  Fournier,  402  had  but  one,  and  154  several 
chancres.  Debauge  collected  60  cases  at  the  Antiquaille  Hospital,  at 
Lyons,  in  41  of  which  there  was  a  single  chancre,  and  in  19  several. 
These  statistics  would  show  that  the  chancre  is  solitary  in  three  cases  to 
one  in  which  it  is  multiple.  The  ratio  is  still  greater  in  M.  Clerc's  obser- 
vations, in  which  the  chancres  were  single  in  224  out  of  267  cases.  If 
multiple  at  all,  it  is  almost  always  true  that  they  are  so  as  the  immediate 
effect  of  contagion,  and  because  several  rents  or  abrasions  were  inoculated 
together  in  the  sexual  act.  If  solitary  at  first,  they  continue  to  be  so  ; 
since  successive  chancres  rarely  spring  up  in  the  neighborhood,  as  in  the 
case  of  the  chancroid,  owing  to  the  fact  that  the  virus  ceases  to  act  u[)on 
the  system  as  soon  as  it  is  once  infected. 

Phmjedcena — Pliagediena  generally  spares  the  chancre  or  limits  its 
ravages  to  the  destruction  of  the  surrounding  induration.  In  some  instances, 
however,  as  I  have  seen  in  my  own  practice,  an  extensive  phagedenic 
ulcer  is  the  initial  lesion  of  syphilis,  and,  in  this  case,  the  subsequent 
general  symptoms  are  usually  of  an  aggravated  character.  Babington 
says :  "  The  secondary  symptoms  which  follow  the  phagedenic  sore  are 
peculiarly  severe  and  intractable.  They  commonly  consist  of  rupia, 
sloughing  of  the  throat,  ulceration  of  the  nose,  severe  and  obstinate  mus- 
cular pains,  and  afterwards  inflammation  of  tlie  periosteum  and  bones. 
Similar  complaints  will  follow  the  ordinary  chancre ;  but  when  they 
follow  a  phagedenic  sore  they  are  very  difficult  to  be  cured ;  and  it  is  not 
uncommon  that  the  constitution  of  the  patient  should  at  length  give  way 
under  them,  and  that  the  case  should  terminate  fatally."^ 

Bassereau  also  found  a  correspondence  between  the  severity  of  the 
chancre  and  that  of  the  syphilitic  eruption.  Thus,  of  68  chancres  which 
preceded  a  pustular  syphilide,  20  were  phagedenic  and  4  others  serpigi- 
nous f  and  18  of  50  chancres  followed  by  a  tubercular  eruption  produced 

'  Etudes  cliniques  des  maladies  ven^riennes  ;  des  plaques  muqueuses.  Arch, 
gen.  de  med.,  4e  s6rie,  vol  ix,  p.  182. 

"^  RicoKD  and  HcjxTER  on  Venereal,  2d  ed.  p.  371.  ^  Qp.  cjt.  p.  442. 


DIAGNOSIS.  459 

destruction  of  the  tissues  to  a  greater  or  less  extent.  It  will  be  recollected, 
on  the  contrary,  that  143  of  170  chancres  followed  by  syphilitic  erythema 
were  mere  erosions,  and  that  10  only  exhibited  a  very  slight  tendency  to 
phagedoBna.  Bassereau  states  that  a  similar  relation  exists  between  the 
primary  sore  and  other  syphilitic  lesions,  and  lays  down  the  rule,  that 
"  mild  syphilitic  eruptions  and,  in  general,  those  constitutional  symptoms 
which  exhibit  but  little  tendency  to  suppurate  follow  the  mild  forms  of 
chancre  ;  while  pustular  eruptions,  and,  at  a  later  period,  ulcerative  affec- 
tions of  the  skin,  exostoses  terminating  in  suppuration,  necroses,  and 
caries,  follow  phagedenic  chancres."  Tlie  degree  of  ulceration  of  the 
chancre  is  also  regarded  by  Diday^  as  one  of  the  most  valuable  indications 
to  enable  us  to  determine  whether  the  attack  of  syphilis  is  to  be  mild  or 
severe,  and  whether  mercury  can  or  cannot  be  dispensed  with  in  the  treat- 
ment. Admitting  the  truth  of  this  rule,  it  does  not  follow  that  the  con- 
dition of  the  chancre  in  any  manner  determines  the  severity  of  subsequent 
symptoms,  but  merely  that  it  is  an  indication  of  the  activity  of  the  virus 
and  of  the  state  of  the  patient's  system — the  two  causes  upon  which  the 
severity  of  the  attack  chiefly  depends. 

Condition  of  the  neighboring  Ganglia — We  have  already  seen  that 
most  chancroids  are  free  from  ganglionic  reaction,  and  that  when  this 
occurs  it  is  always  inflammatory  and  chiefly  involves  one  ganglion,  which 
tends  to  suppuration  and  often  furnishes  inoculable  pus.  The  chancre,  on 
the  contrary,  gives  rise  to  changes  in  the  neighboring  lymphatic  ganglia, 
which,  by  their  constancy,  and  the  peculiarity  of  their  symptoms,  are  of 
the  highest  value  in  diagnosis.  A  number  of  these  bodies  become  enlarged 
and  indurated  in  a  similar  manner  to  the  base  of  the  chancre,  without  in- 
flammatory action  ;  they  do  not  suppurate  except  in  rare  instances,  and  the 
pus  is  never  inoculaVjle.  The  induration  of  the  neighboring  ganglia,  at- 
tendant upon  a  chancre,  will  be  more  fully  described  hereafter. 

Diagnosis  of  the  Ciiaxcre The  most  valuable  diagnostic  signs  of 

a  chancre  are  its  period  of  incubation,  the  induration  of  its  base,  and  the 
induration  of  the  neighboring  ganglia.  Both  of  the  latter  are  rarely,  if 
ever,  wanting.  Of  the  two,  I  believe  induration  of  the  ganglia  to  be  the 
more  constant.  Absence  of  induration  of  the  base  cannot  always  be  de- 
pended upon,  even  according  to  Ricord's  showing,  who  says  that  this 
symptom  sometimes  disappears  after  a  few  days'  duration,  and  it  may,  there- 
fore, have  passed  away  before  the  patient  comes  under  the  care  of  the  sur- 
geon. Cases  are  reported  by  competent  observers  of  chancres  with  a 
perfectly  soft  base,  which  have  yet  been  followed  by  general  syphilis ;  such 
instances,  however,  are  extremely  rare.  If  a  caustic  or  astringent  has 
recently  been  applied  to  a  sore,  induration  of  its  base  should  be  admitted 
with  caution :  examine  the  condition  of  the  neighboring  ganglia  ;  direct 
simple  applications  only  for  a  week  or  two,  and  see  if  the  hardness  persists. 
Inflammation  of  the  surrounding  tissues  may  counterfeit  or   mask  specific 

'  Histoire  naturelle  de  la  sji)hilis,  p.  84. 


460 


INITIAL  LESION  OF  SYPHILIS. 


induration:  here  again,  refer  to  the  ganglia,  or  defer  the  diagnosis  until 
the  inflammatory  products  shall  have  time  to  undergo  absorption. 

Even  admitting  that  cases  may  possibly  occur  in  which  induration  of 
the  base  and  of  the  ganglia  are  both  absent,  yet  these  two  prominent  symp- 
toms of  a  chancre  are  as  constant  and  as  valuable  as  any  others  in  the 
whole  range  of  pathology ;  more  than  this  we  can  neither  ask  nor  expect. 
Since  absorption  of  the  sypliilitic  virus  takes  place  instantaneously  so  soon 
as  it  has  penetrated  beneath  the  epidermis,  and  since  there  is,  therefore,  no 
o[)portunity  of  preventing  constitutional  infection  by  abortive  treatment, 
there  is  less  necessity  for  an  early  diagnosis  than  was  formerly  supposed  ; 
and,  in  obscure  cases,  we  may  wait,  if  necessary,  until  after  the  time 
Avithin  which,  if  ever,  secondary  symptoms  invariably  appear. 

The  su[)erficial  form  of  chancre  does  not  differ  materially  in  appearance 
from  a  common  excoriation,  or  from  the  superficial  ulcerations  of  balanitis  ; 
it  may  be  distinguished  by  its  late  appearance  after  exposure,  its  indura- 
tion, and  greater  pei'sistency.  No  suspicion  of  a  chancre,  however,  may 
be  awakened  if  the  erosion  be  surrounded  by  simple  inflammation  of  the 
mucous  membrane,  unless  the  induration  of  the  inguinal  ganglia  be  dis- 
covered, and  hence  the  condition  of  these  bodies  should  always  be  examined 
in  apparent  cases  of  balanitis. 

Inoculation  of  the  secretion  of  a  sore  u[)on  the  person  bearing  it  is 
presumptive  of  a  chancroid,  but  is  of  less  value  in  the  diagnosis  of  a 
chancre. 


Diagnostic  Characters  of  the  Chancre  and  Chancroid. 

The  Chancre.  The  Chancroid. 

Origin.     (Confrontation.)  Origin.     (Confrontation.) 

Always   due   to    contagion   from   the  In  jjractice  generally  due  to  contagion 

secretion  of  a  chancre,  syphilitic  lesion,  from  a  chancroid,  or  chancroidal  bubo, 

or  from  the  blood  of  a  person   affoctod  or  lymphitis. 
with  syphilis. 

Incubation.  Incubatioii. 

Constant ;  usually  of  from  two  to  three  None.     The   sore    appears    within    a 

weeks'  duration.  week  after  exposure. 


Commencement. 

Commences  as  a  papule  or  tubercle, 
which  afterwards,  in  most  cases,  be- 
comes ulcerated. 


Commencement. 

Commences  as  a  pustule,  or  as  au  open 
ulcer. 


Number.  Number. 

Generally  single  ;  multiple,  if  at  all,  Often  multiple,  either  from  the  first 

from  the  first ;  rarely,  if  ever,  by  sue-  or  by  successive  inoculation, 
cessive  inoculation. 

iJeptfi.  Depth. 

Most  frequently  a  superficial  erosion,  Perforates  the  whole  thickness  of  the 

"scooped  out,"  flat,  or  elevated  above  skin  or  mucous  membrane;   "punched 

the  surface ;  rarely  deep,  and  then  cup-  out,"  and  excavated. 
shaped,  sloping  towards  the  centre. 


DIAGNOSIS. 


461 


Edges. 

Sloping,  flat,  or  rounded,  adherent. 

Floor. 


Edges. 

Abrupt,  sharply  cut,   eroded,  under- 
mined. 

Floor. 


Red,    livid,    or    copper-colored,   often  Whitish,  grayish,  pultaceous,  "worm- 
iridescent.    Sometimes  covered  by  a  false  eaten." 
membrane,  scaly  exfoliation,  or  scabs. 

Secretion.  Secretion. 

Scanty  and  serous,  in  the  absence  of  Abundant  and  purulent, 
complications. 

Auto-inoculable  with  great  difficulty.  Readily  auto-inoculable. 

Inditration.  Induration. 

Firm,  cartilaginous,  circumscribed,  No  induration  of  base,  although  en- 
movable  upon  neighboring  tissues  ;  gorgement  may  be  caused  by  caustic 
sometimes  thin,  resembling  a  layer  of  or  other  irritant,  or  by  simple  inflamma- 
parchment,  or,  again,  annular  ;  gene-  tion  ;  in  which  case  the  engorgement  is 
rally  persistent  for  weeks  or  months.  not  circumscribed,  shades  oflT  into  sur- 
rounding tissue,  and  is  of  short  duration. 

Sensihilitg.  Sensibility. 

So  little  painful  as  often  to  pass  un-  Painful, 
noticed. 


Destructive  tendency. 

Phagedaena  rare  and  generally  lim- 
ited. 

Frequency  in  the  same  subject. 

One  chancre  usually  affords  comjjlete, 
and  always  partial  protection  against 
another. 

Lynijthitis. 

Induration  of  the  lymphatics  common. 


Destructive  tendency. 

Often  spreads  and  takes   on   phage- 
denic action. 

Frequency  in  the  same  subject. 

May  affect  the  same  person  an  inde- 
finite number  of  times. 

Lymphitis. 

Inflammation  of  the  lymphatics  rare. 


Characteristic  gland  affection.  Characteristic  gland  affection. 

Tlie  superficial  ganglia  on  one  or  both  Ganglionic  reaction  absent  in  the  ma- 
sides  enlarged  and  indurated,  painless,  jority  of  cases.  When  present,  inflam- 
freely  movaVjle  ;  suppuration  rare  and  matory  ;  suppuration  frequent,  pus  often 
pus  never  auto-inoculable.  auto-inoculable. 


Transmission  to  animals. 
Peculiar  to  the  human  race. 

Prognosis. 

A  constitutional  disease.  General 
symptoms  usually  occur  in  about  six 
weeks  after  the  appearance  of  tlie  sore, 
and  very  rarely  delay  longer  than  three 
months. 

Effects  of  treatment. 

Improves  under  the  influence  of  mer- 
cury. 


'Transmission  to  animals. 

May  be  transmitted  to  the  lower  ani- 
mals. 

Prognosis. 

Always  a  local  aflfection  ;  the  general 
svstem  never  infected. 


Effects  of  treatment. 

Treatment  by   mercury   always    use- 
less, and,  in  most  cases,  injurious. 


4G2  INITIAL    LESION    OF    SYPHILIS. 

Pathological  Anatojiy Kaposi  gives  the  following  account  of  the 

microscopical  appeai'ances  of  sections  of  a  chancre  : — 

"  In  the  histological  investigation  of  the  hard  chancre,  the  point  of 
greatest  interest  is  the  minute  anatomy  of  the  induration.  In  a  perpen- 
dicular section,  the  microscope  shows  a  uniformly  and  thickly  distributed 
deposit  of  cells  in  the  papillae  and  in  the  corium  throughout  its  whole 
thickness  down  to  the  subjacent  cellular  tissue.  This  cell  infiltration  is 
limited  somewhat  abruptly  at  the  sides  and  below,  and  is  suiTounded  by 
a  coarse  (tcdematous)  tissue  of  fibres,  in  wliich  are  found  irregularly  dis- 
tributed cells  containing  a  large  nucleus  that  strongly  refracts  the  light. 

"  Under  a  higher  power  the  infiltrated  cells  of  the  induration  are 
roundish,  corresponding  in  size  to  granulation  cells,  but  generally  some- 
what smaller,  with  one  or  two  nuclei  and  a  finely  dotted  protoplasm 
evidently  overlying  the  enclosed  nucleus. 

"The  cells  are  deposited  in  a  network  of  narrow  meshes,  whose  walls 
are  tliin  and  somewhat  sharply  outlined.     Corresponding  to  the  surface  of 

Fis.  11(5. 


'/ 


Section  of  a  Chancre,  Hartnack,  oc.  ^^  ;  ohj.  4.  (After  Kaposi.)  a  h,  surface  of  tlio  ulcer.  The 
indurated  mass  lieneath,  to  the  base  of  the  section  g,  is  uniformly  infiltrated  with  small  cells,  d, 
papillie  hypertvophied  and  infiltrated  with  cells.  The  epidermic  layer  covering  them,  becomes 
thinner  and  thinner  up  to  a,  where  it  disappears.  At  c  anj  h  are  si'oii  remains  of  the  epidermis, 
and,  beneath,  an  infiltrated  papilla,  which  can  only  ne  recognized  by  its  ascending  vessels.  In 
the  indurated  mass  are  several  vessels  with  thickened  walls  and  contracted  calibre,  e,  a  vessel 
cut  longitudinally.    /,  a  vessel  cut  transversely. 

the  lUcer,  the  network  and  its  cell-deposit  is  irregularly  exposed.  Here, 
as  well  as  in  the  parts  lying  nearest  the  surface,  the  cells  are  mixed  with 
numerous  isolated  nuclei,  small  shrivelled  cells,  larger  cells  filled  with 
granular  elements,  and  free  nucleoli. 


PATHOLOGICAL    ANATOMY.  463 

"  The  papillae,  Fig.  IIG,  d,  at  the  sides  of  the  ulcer  are  preserved,  but 
are  thickened,  club-shaped,  and  infiltrated  with  cells  extending  from  the 
corium.  The  rete  between  them  and  especially  over  them  is  much 
thinned.  At  several  points  on  the  surface  of  the  ulcer  are  remnants  of 
the  epidermis  and  the  rete,  lying  on  the  infiltrated  corium.  At  still  other 
points  traces  of  the  papillae  are  seen  with  indications  of  the  slings  of  the 
vessels,  Fig.  116,  c  b. 

"Within  the  cell-infiltrated  portion  there  are  but  few  bloodvessels,  the 
walls  of  which  are  notably  thickened,  and  their  calibre  diminislied  in  size." 

These  microscopical  appearances  should  be  compared  with  those  of  the 
chancroid  given  on  page  364,  and  their  resemblance  is  so  great  as  to  lead 
Kaposi  to  say  :  "  It  appears  to  me  allowable,  from  a  histological  stand- 
point, to  regard  the  hard  chancre  as  different  from  the  soft  only  in  the 
intensity  and  suddenness  of  the  cell-infiltration  and  cell-degeneration,  but 
not  in  their  essence." 

Since  Kaposi's  observations,  however,  further  light  has  been  thrown  on 
this  subject  by  Caspary*  and  others,  but  especially  by  the  admirable  inves- 
tigations of  Auspitz'^  and  Unna.^ 

Caspary  arrived  at  the  following  conclusions:  "The  essential  difference 
in  the  structure  of  the  soft  and  hard  chancres  consists  in  this,  that  in  the 
latter  a  new  growth  of  connective  tissue  occurs,  which  in  the  former  is 
not  developed  at  all,  in  consequence  of  the  loss  of  tissue  (destructive  meta- 
morphosis) which  is  constantly  going  on.  Tiiis  new  formation  is  charac- 
terized, even  in  recent  indurations,  by  a  firm,  closely-woven  network 
everywhere  inclosing  the  cells;  in  old  indurations,  by  entire  bundles  of 
fibres  which  interpenetrate  the  new  growth  of  cells.  The  narrowing  of 
the  vessels,  which  I  could  not  demonstrate  in  fresh  cases,  appears  to  me 
to  be  the  effect,  not  the  cause,  of  the  sclerosis.  It  appears  to  me  probable 
that  the  formation  of  fibres  proceeds  from  the  infiltration  cells,  and  not 
from  the  growth  of  young  connective  tissue  occurring  at  the  periphery, 
and  extends  into  the  interior  of  the  neoplasm,  because  such  a  growth  has 
not  been  found  in  the  interior  of  the  sclerosis.  I  would  look  upon  the 
embryonic  connective  tissue  found  at  the  periphery  as  a  kind  of  capsule 
caused  by  reactionary  inflammation." 

Auspitz  and  Unna  iiave  furtlier  studied  the  changes  in  the  vessels  of  the 
mass  of  induration,  resulting  in  a  diminution  of  tlicir  calibi'e  or  in  their 
complete  obliteration,  which  they  compare  to  those  observed  by  Ileubner 
in  the  arteries  of  the  brain ;  and  they  express  the  opinion  that  in  future 
investigations  of  syphilitic  neoplasms,  the  condition  of  tlie  vessels  is  the 
chief  point  for  study.  As  to  the  manner  in  which  tliese  changes  take 
place,  Unna  concludes: — 

'  Vierteljschft  f.  Derm.  u.  Sypli.,  Wien,  1876,  s.  45. 

2  An.'itomie  d.  syphil.  Initial  Sklerose,  von  Prof.  Heinr.  Auspitz  u.  Dr.  Paul 
Unna,  Vierteljschft  f.  Derm.  u.  Syph.,  1876,  s.  161. 

'  Zur  Anatomie  der  syphil.  Initial-sklerose,  VierteljsLhft  f.  Dorm.  ii.  Syph., 
1878,  s.  531. 


464 


INITIAL    LESION    OF    SYPHILIS. 


1.  The  fibrous  constituent  of  the  cutis,  which,  through  its  hypertrophy, 
occasions  the  hardness  of  the  initial-sclerosis,  is  composed  of  pure  collagen.^ 

2.  A  sclerosed  vessel  arises  in  consequence  of  the  fibrous  hypertrophy 
of  the  connective  tissue  of  the  outer  coat  (adventitia)  attended  by  the 
disappearance  of  the  lymph-meshes  (comi)licated  with  more  or  less  infil- 
tration of  round  cells),  and  of  the  same  change  in  the  connective  tissue 
immediately  surrounding  the  vessel. 

3.  In  endarteritis  obliterans  syphilitica  acuta,  as  takes  place  in  the 
initial-sclerosis,  the  thickening  of  the  endothelium  is  certainly  not  the  first 
change.  The  constant  and  early  implication  of  the  vasa  vasorum  renders 
it  probable  that  the  starting  point  is  here.  Where  there  are  no  vasa 
vasorum  the  pathological  process  always  begins  in  the  outer  coat. 

4.  Still  more  extended  than  the  typical  endarteritis  obliterans  is  the 
closure  of  the  vessels  tlirough  obliteration  of  the  walls  by  means  of  round- 
cells  (granulating  arteritis).  Both  processes,  independent  of  each  other, 
combine,  and  one  may,  by  its  excessive  development,  crowd  out  the  other. 
The  larger  vessels  are  most  frequently  the  victims  of  endarteritis  obliterans, 
the  smaller,  especially  the  capillaries,  of  closure  through  infiltration. 

Figs.  117  and  118,  taken  from  Unna's  latest  paper  on  this  subject, 
admirably  represent  the  changes  which  take  place. in  the  arteries.  The 
sections  are  represented  as  they  appeared  after  having  been  prepared  and 
colored. 

Fig.  117. 


Section  of  an  artery,  vein,  aud  lyinpliatic,  highly  magiiifled. 

In  Fig.  117  are  seen  sections  of  an  artery  (a),  a  vein  (i),  and  a  Ij'niph- 
atic  (/).  In  the  tunica  intima  of  the  artery  the  nuclei  of  the  endothelium 
are  very  marked  and  appear  to  project  more  than  usual  into  the  lumen. 

'  For  the  properties  of  "  collagen,"  see  Dalton's  Treatise  on  Human  Physiology, 
6th  cd.,  1875,  p.  91. 


PATHOLOGICAL    ANATOMY. 


465 


The  whole  intima  is  in  a  swollen  condition.  The  media  is  also  swollen 
and,  like  the  intima,  more  yellow  than  normal;  the  nuclei  of  the  muscular 
fibres  are  sharply  shown.  Round  cells,  in  rows  and  in  groups,  are  first 
seen  at  the  border  line  between  the  media  and  the  adventitia,  and  espe- 
cially at  a  spot  where  a  clear  lumen  is  seen  to  be  thickly  and  concentrically 
surrounded  by  round  cells,  and  where  also  a  small  nutrient  vessel  enters 
as  far  as  the  media.  The  adjoining  portion  of  the  adventitia  is  more 
thickly  infiltrated  with  round  cells  than  elsewhere. 

The  same  appearance  is  presented  in  the  adventitia  of  the  vein :  thick 
bundles  of  connective  tissue,  separated  by  isolated  round  cells  and  regions 
of  the  same, — but  the  round  cells  are  here  generally  more  abundant,  and  in 
the  upper  quadrant  especially  they  completely  mask  the  structure  of  the 
media.  The  most  striking  appearance,  however,  in  the  vein,  is  the  ex- 
uberance of  the  endothelial  cells,  which  changes  the  shape  of  the  lumen  to 
that  of  an  irregular  pentagon.  In  marked  contrast  to  this  is  the  condition 
of  the  lymphatic  endotlielium,  which  is  not  at  all  changed.  Several  small 
vasa  vasorum  (e,  e)  are  seen  thickly  surrounded  and  partially  closed  by 
round  cells.  The  surrounding  cellular  tissue  (&)  presents  hypertrophied 
fibrillae  and  round  cells. 

A  later  stage  of  the  above  process  is  shown  in  Fig.  118,  in  which  a  is 
probably  an  artery,  h  a  vein,  and/"  a  lymphatic.  The  first  two  are  oblite- 
rated or  nearlv  so,  while  the  last  is  unaffected. 


Fig.  118. 


Similar  sections  showiug  ouliter.itioa  of  tlie  artery  and  vein. 

Virchow,^  in  his  celebrated  work  on  the  Pathology  of  Syphilis,  advocated 
the  complete  correspondence  of  an  indurated  chancre  with  a  gumma  of  the 
skin.  The  identity  of  these  two  lesions  is^  not  now,  however,  to  be 
maintained,  as  is  shown  by  the  following  comparison  of  the  two. 

"  A  gumma  is  a  collection  of  small  cells  with  large  nuclei,  lying  in  a 
network  of  fine  connective  tissue.  It  forms  a  roundish  mass,  whose 
separation  from  tlie  neighboring  tissues  is  more  apparent  on  gross  than 
on  microscopical  examination.  Its  regular  course  is  to  undergo  dry 
atro])]iy  (cheesy  degeneration),  or  fatty  degeneration  and  ulceration.     Fre- 

'  Ueber  die  Natur  der  constitutionell-syphilitischen  Affectionen,  1859. 
30 


466  INITIAL    LESION    OF    SYPHILIS. 

quently,  especially  in  the  cutis,  it  is  surrounded  by  sclerosed,  brittle  bundles 
of  connective  tissue,  but  we  can  ap^jly  the  name  of  gumma  only  to  the  cen- 
tral, <>um-like,  richly  cellular  mass,  which,  especially  in  the  corium,  almost 
always  forms  an  abscess. 

"The  initial  sclerosis,  on  the  other  hand,  presents  a  syphilomatous,  new 
cell-o-rowth,  permeated  by  a  new  formation  of  fibrous  connective  tissue, 
which  of  itself  renders  the  formation  of  cavities  of  considerable  size  im- 
possible. No  tendency  to  the  formation  of  even  miliary  abscesses  is  shown." 
(Unna.J 

Treatment  of  the  Chancke It  was  formerly  supposed  that  a  chan- 
cre was  at  first  a  mere  local  affection,  and  that  the  general  circulation  did 
not  become  contaminated  until  some  days  after  the  appearance  of  the  ulcer  ; 
and  hence  that  its  early  and  complete  removal  was  capable  of  averting 
infection. of  the  constitution.  The  advice  was  therefore  given  to  cauterize 
or  excise  a  chancre  as  soon  as  it  appeared ;  and  we  were  told,  that,  if  the 
caustic  was  sufficiently  powerful  to  kill  the  tissues  to  an  extent  exceeding 
the  sphere  of  specific  influence  of  the  virus,  or  if  the  excison  was  carried 
to  a  sufficient  extent,  a  simple  wound  would  be  left  after  the  fall  of  the 
eschar,  and  our  patient  would  be  preserved  from  syphilitic  infection.  This 
treatment,  known  as  the  "  abortive  treatment  of  chancre,"  was  supported 
by  the  distinguished  names  of  Ricord  and  Signiund,  who  assigned  the 
fourth  day  after  contagion  as  the  limit  within  which  destructive  cauteriza- 
tion could  be  employed  with  a  certainty  of  success  ;  but  it  should  be  known 
that  these  surgeons  have  since  abandoned  their  early  views  on  this  subject. 

Belief  in  the  efficacy  of  "  the  abortive  treatment"  never  could  have  been 
entertained,  had  it  not  been  for  confounding  the  chancroid  and  sy[)l!ilis, 
whereby  surgeons  were  led  to  believe  that  when  a  patient  whose  chancroid 
had  been  cauterized  escaped  general  syphilis,  post  hoc  eryo  propter  hoc 
his  immunity  was  due  to  the  cauterization. 

A  chancre  is  never  a  mere  local  lesion,  as  is  proved  by  its  period  of 
incubation,  by  the  analogy  of  other  morbid  poisons,  and  by  the  fact,  as 
shown  by  repeated  experiments,  that  its  destruction  within  a  few  days 
and  even  a  few  hours  after  its  appearance  fails  to  avert  constitutional  in- 
fection. 

The  average  duration  of  the  incubation  of  a  chancre  is,  moreover,  from 
two  to  three  weeks.  During  this  period  the  inoculated  point  remains  in  a 
state  of  quiescence  and  exhibits  no  traces  of  inflammation  ;  hence  the  sub- 
sequent appearance  of  the  chancre  can  only  be  ascribed  to  the  reaction  of 
the  absorbed  virus.  It  may  be  remarked,  in  passing,  that  this  period  of 
incubation  renders  the  conditions  of  the  so-called  abortive  treatment 
(cauterization  within  four  days  after  contagion)  impracticable,  since  the 
sore  very  rarely  appears  until  the  time  specified  has  elapsed  ;  and  the  same 
consideration  increases  the  probability  that  Ricord  and  Sigmund,  in  their 
"  thousands"  of  supposed  successful  cases,  really  applied  the  method  only 
to  the  chancroid.  Experiments  with  other  morbid  poisons  prove  that 
absorption  is  almost  instantaneous.     Bousquet  inoculated  the  vaccine  virus, 


TREATMENT    OP    THE    CHANCRE.  46t 

and  immediately  applied  cups  and  washed  the  parts  with  chlorinated  water 
without  preventing  the  evolution  of  a  pustule.^  Renault,  Surgeon  of  the 
Veterinary  School  at  Alfort,  inoculated  horses  with  acute  glanders,  excised 
the  part  and  applied  the  actual  cautery  one  hour  afterwards,  yet  the 
animals  died  of  the  disease.'^  Similar  experiments  with  the  sheep-pox 
virus  proved  that  its  absorption  does  not  require  more  than  five  minutes. 
Hence  analogy  would  show  that  the  syphilitic  virus  also  reaches  the  gene- 
ral circulation  almost  instantaneously  after  its  implantation  beneath  the 
epidermis. 

We  have  still  farther  the  evidence  of  direct  experiment.  Numerous  cases 
are  recorded  in  which  destructive  cauterization  within  a  few  days,  and 
ei:en  a  feiv  hours  after  the  development  of  the  chancre^  has  failed  to  avert 
constitutional  infection.  Diday  has  thoroughly  cauterized  chancres  within 
four  days  and  a  half,  and  others  within  five  days,  and  secondary  symptoms 
have  still  appeared.  In  another  case,  occurring  in  a  patient  who  had 
watched  himself  with  the  greatest  care  from  day  to  day  and  almost  from 
hour  to  hour,  the  chancre  was  not  developed  uniil  a  month  after  the  sexual 
act,  but  the  abortive  treatment  was  applied  within  six  hours  of  its  first 
appearance ;  the  sore  healed  in  the  course  of  three  days,  but  secondary 
symptoms  appeared  three  weeks  afterwards.*  More  recently,*  Diday  has 
reported  several  additional  cases. 

It  was  desirable  that  thus  much  should  be  said  in  deference  to  any  of 
our  readers  who  may  have  imbibed  their  only  notions  of  venereal  from  the 
teachings  of  authorities  a  few  years  ago  ;  but  the  "abortive  treatment  of 
syphilis"  is  now  so  generally  recognized  to  have  been  founded  in  error, 
that  we  need  not  dilate  farther  on  the  subject. 

But  if  destructive  cauterization  is  inefficacious  as  a  means  of  preventing 
constitutional  infection,  it  is  equally  unnecessary  in  most  cases  for  tlie 
purpose  of  hastening  the  cicatrization  of  the  chancre,  which  rarely  tends 
to  spread,  and  which  is  commonly  sufficiently  under  the  control  of  mercury. 
I  would,  therefore,  limit  its  application  to  those  few  chancres  Avhich  are 
complicated  with  phageda^na,  and  to  those  cases  in  which  conjugal  relations 
and  the  necessity  of  secrecy  render  it  desirable  to  effect  cicatrization  of 
the  sore  as  speedily  as  possible  in  order  that  coitus  may  be  indulged  in 
with  comparative  safety.  Even  then,  it  is  a  question  whether  much  time 
wmU  be  gained  by  its  use.  When  employed,  induration  usually  reappears 
in  the  wound,  and  general  lesions  are  developed  within  tlie  normal  period. 
The  m.ode  of  its  application  has  already  been  described. 

Excision  of  Chancres Excision  of  chancres  with  the  view  of  aborting 

syphilis  was  practised  in  earlier  years,  but  was  afterwards  abandoned  on 
account  X)f  its  failure  to  accomplish  the  object.  Tlie  method  has  of  late 
years  been  again  revived  and  advocated,  especially  by  Auspitz,  Koliiker, 
and  Otis.     During  the  past  ten  years  we   have  ourselves  carefully  tested 

*  Traite  de  la  vaccine.  *  Acad(;mie  des  sciences,  1849. 
3  Gaz.  ni6d  de  Lyon,  1  mars,  1858. 

*  Anuuaire  de  la  sypli.  et  d.  iiial.  de  le  \wa.\\,  Paris,  annee  1858,  p.  134. 


468  INITIAL    LESION    OF    SYPHILIS. 

this  form  of  treatmont  in  fifteen  cases.  Tliose  wlio  rely  upon  it  as  a  means 
of  aborting  syphilis  regard  the  disease  in  its  primary  stage  as  merely 
local,  a  position  which  we  are  not  yet  willing  to  assume.  We  shall,  how- 
ever, give  the  details  of  the  treatment  and  its   most  important  results. 

The  observations  of  Auspitz  were  made  upon  thirty-three  cases,  from 
which  his  conclusions  are  drawn  with  such  care  that  we  shall  give  them 
here  in  brief.  It  is  his  custom  to  seize  the  tissues  with  an  anatomical 
pincette,  with  toothed  forceps,  or  with  a  serre-fine,  and  elevating  the  parts, 
to  cut  with  scissors  well  beneath  the  indurated  mass.  The  surface  of  the 
wound  generally  bleeds  but  little,  and  should  be  carefully  examined  to 
avoid  leaving  any  indurated  tissue.  In  some  cases  the  wound  is  closed 
>vith  a  few  sutures,  or  a  carbolized  compress  is  applied. 

In  several  of  our  own  operations,  in  case  of  extensive  and  deep  indura- 
tion, we  passed  several  threads,  for  the  purpose  of  traction,  under  the  mass 
and  transfixed  the  parts  beneath  the  threads,  cutting  outwards  in  one  direc- 
tion and  then  in  the  other.  In  some  cases  of  long  prepuce,  where  the 
chancre  was  seated  at  its  free  margin,  the  excision  was  performed  by  a 
single  cut  of  the  knife  or  scissors.  Previous  to  the  operation,  the  parts 
should  be  thoroughly  cleansed,  and  the  nodule  should  be  cauterized  with 
equal  parts  of  water  and  carbolic  acid.  In  two  of  our  cases  induration 
recurred  in  the  cicatrix. 

Auspitz  says  that  phagedajna  and  a  diphtheritic  condition  were  observed 
by  him  in  a  few  instances,  and  in  most  cases  the  inguinal  ganglia  were 
indurated.  The  latter  feature  was  present  in  all  of  our  cases.  The  indura- 
tion is  regarded  by  Auspitz  not  as  an  indication  of  infection,  but  as  an  ordi- 
nary result  of  the  local  inflammatory  process  on  the  penis.  In  fourteen  of 
his  thirty-three  cases  no  syphilis  followed.  This  experience  is  decidoTily 
at  variance  with  our  own  ;  we  have  never  succeeded  in  aborting  syphilis 
by  this  procedure.  Auspitz  recommends  excision  in  cases  of  recent  indu- 
ration, even  though  accompanied  by  indolent  enlargement  of  the  inguinal 
ganglia.  Chancres  on  the  external  surface  of  the  limbs  and  on  the  pre- 
puce are  selected  as  most  l"avorable  for  operation,  while  those  in  the  sulcus 
coronarius  are  considered  unfavorable. 

The  results  of  Kolliker  with  this  operation  are  of  interest.  In  seven 
out  of  eiglit  cases  he  excised  a  chancre  on  the  seventh,  the  ninth,  the  tenth, 
the  fourteenth,  the  twenty-first,  and  the  forty-ninth  day  after  its  appearance, 
while  in  one  case  the  date  is  not  given.  In  six  the  wound  healed  by  first 
intention,  and  in  two  by  granulation.  In  three  cases  induration  appeared 
in  the  cicatrix,  and  in  two  of  these  sy()hilis  followed,  while  in  two  other 
cases  induration  apjjcared  later  and  was  the  forerunner  of  syphilis.  Kolli- 
ker says  that  in  but  tliree  of  his  cases  was  syphilis  probably  aborted  or 
prevented  by  excision.  He  concludes  that  in  certain  cases,  excision  may 
prevent,  retard,  or  modify  constitutional  infection.  He  does  not  regard 
lymphatic  induration  as  a  contra-indication,  and  like  Auspitz,  thinks  "  that 
the  chancre  is  not  to  be  considered  an  expression  of  constitutional  infec- 
tion." 

In  the  local  treatment  of  chancres,  cleanliness  and  the  interposition  of 


TREATMENT  OF  THE  CHANCRE.  469 

some  absorbing  medium,  as  dry  lint,  are  of  the  same  importance  as  in  the 
treatment  of  the  chancroid.  Tiie  same  rules  should  also  govern  us  in  the 
selection  of  any  medicated  applications,  except  that  on  theoretical  grounds 
at  least,  mercurials  may  be  used  with  some  show  of  reason,  and  "black 
wash"  may  not  be  entirely  lost  to  memory.  Fatty  preparations  of  mercury 
are  not  to  be  recommended  when  the  chancre  is  seated  within  the  balano- 
preputial  fold,  but,  when  seated  on  the  external  integument,  the  unguen- 
tum  hydrargyri,  the  mercurial  plaster,  or  the  emplastrum  de  vigo  cum 
mercurio  will  usually  be  found  to  be  good  applications.  In  the  superficial 
variety  of  chancre  which  is  the  most  frequent,  the  degree  of  ulceration 
and  the  amount  of  the  secretion  are  so  slight,  that  the  simple  interposi- 
tion between  the  glans  and  prepuce  of  a  piece  of  dry  lint,  or  lint  soaked 
in  some  mild  astringent,  is  all  that  is  necessary,  and  the  dressing  need  not 
be  changed  oftener  than  once  or  twice  in  the  twenty-four  hours. 

General  Treatment The  chancre  is  decidedly  under  the  influence  of 

mercury,  and  presents  in  this  respect  a  marked  contrast  to  the  chancroid. 
Under  the  use  of  this  mineral  reparative  action  is  speedily  induced,  and 
unless  the  ulcer  be  deep  and  extensive  or  the  system  much  depressed, 
complete  cicatrization  may  be  promised  the  patient  in  the  course  of  from 
one  to  three  weeks. 

I  do  not  propose  at  present  to  enter  fully  into  the  subject  of  the  treat- 
ment of  syphilis,  which  of  course  includes  the  treatment  of  its  initial 
lesion.  A  few  remarks,  however,  may  be  better  made  here  than  elsewhere. 
And,  in  the  first  place,  let  me  say  that  no  course  of  mercury  administered 
for  a  chancre,  however  thorough  or  prolonged,  is  likely  to  prevent  the  sub- 
sequent evolution  of  general  manifestations.  Some  eminent  authorities 
maintain  the  contrary,  but  their  opinion  has  not  been  confirmed  by  our 
own  experience.  In  the  very  many  attempts  that  we  have  made  to  sub- 
due the  disease  during  the  existence  of  the  initial  lesion  and  prior  to  the 
appearance  of  general  manifestations,  we  have  alvvays  failed.  Moreover, 
although  the  use  of  mercury  retards  the  appearance  and  probably  amelior- 
ates the  severity  of  secondary  symptoms,  yet  it  is  a  fact  attested  hy  many 
observers,  ourselves  included,  that  those  cases  ultimately  do  best,  in  tohich 
specific  treatment  is  deferred  until  the  secondary  stage. 

The  exceptional  cases  of  chancre  in  which  it  is  advisable  to  administer 
mercury  before  secondary  symptoms  appear  may  be  summed  up  as 
follows : — 

1.  Chancres  Avhich,  from  their  size,  depth,  and  progress,  occasion  pain 
and  inconvenience,  or  which  threaten  to  destroy  important  parts. 

2.  Chancres  occurring  in  married  persons  who  cannot  long  avoid  sexual 
intercourse  without  exciting  suspicion. 

3.  CHancres  in  persons  who  are  either  too  anxious  or  too  unreasonable 
to  be  willing  to  submit  to  delay. 

In  other  cases,  especially  when  the  sore  is  superficial  and  attended  with 
little  or  no  inconvenience,  we  prefer  to  (h'lay  the  use  of  mercury  until 
secondary  synq)toms  appear,  meanwhile  resorting  to  tonics,  as  one  of  the 
preparations  of  iron,  iodide  of  potassium,  or  cod-liver  oil. 


470  INITIAL    LESION    OP    SYPHILIS- 

In  using  mercurials  during  this  period  of  sypliilis,  we  commonly  employ 
either  the  blue  mass  or  gray  powder ;  giving  one  or  two  grains  of  the 
former,  or  from  three  to  five  grains  of  the  latter,  twice  a  day  for  a  week  ; 
increasing  the  dose  at  the  end  of  that  time  if,  as  is  rarely  the  case,  there 
is  no  perceptible  effect  upon  the  ulcer;  always  avoiding  action  upon  the 
gums  and  bowels,  and  suspending  treatment  as  soon  as  reparative  action 
is  established.  After  cicatrization  of  the  sore  it  is  desirable  to  resort  to 
iodide  of  potassium  and  iron,  in  order  to  combat  the  chloro-anajmia 
which  exists  in  the  early  stage  of  syphilis,  and  thus  diminish  the  severity 
of  the  premonitory  symptoms  which  usually  usher  in  secondary  manifes- 
tations, when  mercui'ials  should  at  once  be  resumed. 


CHANCRES    OF    THE    URETHRA.  471 


CHAPTER    IV. 

SPECIAL    INDICATIONS    FROM    THE     SEAT    OF 
CHANCRES. 

Under  this  head  there  is  much  less  to  be  said  than  has  already  been 
presented  with  regard  to  the  indications  arising  from  the  seat  of  chancroids, 
for  the  reason  that  a  chancre  is  merely  the  initial  lesion  of  a  constitutional 
disease,  while  the  chancroid  is  a  local  affection,  and  is  to  be  treated  as 
such. 

Chaxcres  of  the  urethra  are  more  frequent  than  is  commonly  sup- 
posed, and  are  much  more  common  than  the  chancroid  in  this  locality. 
Our  experience  leads  us  to  believe  that  they  occur  with  rather  more 
frequency  in  Jews  and  in  patients  who  have  a  short  prepuce.  They  are 
found  most  frequently  at  the  meatus  and  in  the  fossa  navicularis,  but  we 
have  seen  several  one,  two,  and  even  three  inches  from  the  orifice. 

Chancres  at  the  meatus  are  sometimes  seated  on  one  lip  only,  but  they 
usually  involve  the  entire  circumference  of  the  canal.  They  first  attract 
attention  by  causing  a  slight  impediment  in  urination,  and  the  mucous 
membrane  is  found  to  be  thickened,  and  the  li[)s  glued  together  by  a  scanty 
viscid  discharge.  The  whole  canal  at  the  site  of  the  ulcer  finally  becomes 
thickened  and  rigid,  and  it  is  often  impossible,  owing  to  the  congestion  of 
the  parts,  to  clearly  circumscribe  the  induration.  The  normal  opening  of 
the  urethra  often  becomes  greatly  reduced,  even  to  the  size  of  the  head  of 
a  pin,  so  that  the  pain  and  difficulty  of  micturition  are  excessive.  The 
parts  have  a  reddish-blue  appearance,  and  give  forth  a  muco-pus.  The 
urethral  walls  are  excoriated  rather  than  ulcerated,  and  very  often  a  few 
drops  of  urine  escape  several  minutes  after  urination.  The  case  is  fre- 
quently mistaken  by  the  inexperienced  for  an  anomalous  case  of  gonorrlifca. 

Chancres  of  the  fossa  navicularis  and  of  the  deeper  parts  begin  pain- 
lessly, with  mere  gluing  of  the  lips  of  the  meatus  as  their  first  symptom. 
Soon  there  is  slight  pain  as  the  urine  first  passes,  and  the  patient  discovers 
a  thickening  of  the  tissues  at  the  site  of  the  chancre.  The  discharge  is 
sometimes  muco-purulent,  but  again  may  be  decidedly  purulent  and  as 
consideiable  in  quantity  as  in  ordinary  gonorrha-a.  This  is  due  to  the 
fact  that  the  lesion  sets  up  a  urethritis  of  the  contiguous  membrane.  Ex- 
ternally is  found  in  the  corpus  spongiosum  a  hard,  tender,  circumscribed 
nodule,  wliich  gives  pain  on  urination  and  on  erection  of  the  penis. 
AVith  the  endoscope  we  observe  rigidity  and  erosion  of  the  urethi-al  walls, 
which  have  a  grayish-red  color.  This  lesion  is  sometimes  very  chronic, 
and  gives  remarkably  little  inconvenience.     It  then  occasions  hard,  non- 


472  INDICATIONS    FROM    SEAT    OF    CHANCRES. 

inflammatory  thickening  of  the  prepuce  on  either  side  of  the  frjenum,  a 
phenomenon  so  constant  in  our  observation  as  to  be  of  considerable  diag- 
nostic value. 

Cliancres  several  inches  from  the  meatus,  acting  like  true  fibrous  stric- 
tures, often  cause  much  inconvenience.  They  may  be  as  large  as  a  pea, 
or,  exceptionally,  of  the  size  of  a  nutmeg.  They  are  always  accompanied 
by  induration  of  the  inguinal  ganglia,  and  sometimes  by  engorgement  and 
induration  of  the  lymphatics,  which  arise  at  the  side  of  the  fra;num. 

After  the  disappearance  of  a  chancre  of  the  urethra  the  parts  may  be 
restored  to  their  normal  condition,  or  thickening  and  contraction  may 
result,  requiring  to  be  relieved  by  internal  urethrotomy  or  slitting  of  the 
meatus. 

The  importance  of  distinguishing  these  chancres  from  gonorrhoea  is 
evident.  Tiie  chief  aids  to  diagnosis  are  the  slight  gluey,  perhaps  bloody, 
discharge,  the  localized  impediment  to  urination,  and  the  subacute  course 
of  the  lesion.  When  the  lesion  is  fully  developed,  the  patient  himself 
usually  calls  attention  to  the  induration. 

The  symptoms  induced  by  these  chancres  are  sometimes  so  urgent  that 
an  active  mercurial  treatment  is  demanded  even  before  the  evolution  of 
secondary  manifestations.  In  ordinary  cases  we  have  found  benefit  from 
the  use  of  bougies  made  of  mercurial  ointment  two  parts  and  white  wax 
six  parts.  These  are  sufficiently  rigid,  and  when  made  conical  at  the  end, 
and  of  a  diameter  of  a  line  or  two,  can  be  I'eadily  introduced  and  retained. 
They  produce  a  beneficial  effect  by  the  gentle  pressure  which  they  exert 
as  well  as  by  their  medicinal  action.  They  are  particularly  efficacious  when 
the  pressure  of  an  ordinary  bougie  cannot  be  borne.  In  some  cases  we 
have  used  similar  bougies  with  one  drachm  of  iodoform  thoroughly  inot)r- 
porated  in  each  ounce  of  the  other  ingredients. 

Chancres  of  the  Anus Statistics  prove  that  chancres  of  the  anus 

are  much  less  common  in  the  United  States  than  upon  the  Continent  and 
in  South  America.  In  the  latter  country,  especially,  the  practice  of 
Sodomy  is  sadly  prevalent,  and  the  occurrence  of  anal  chancres  corre- 
spondingly frequent. 

Jullien,  in  his  elaborate  work  on  venereal,  records  11  chancres  of  the 
anus  out  of  2170  chancres  of  tiie  male  sex,  and  39  out  of  473  in  females, 
making  a  [jroportion  of  1  to  119  in  men  and  1  to  12  in  women. 

Such  chancres  may  be  situated  entirely  without  the  anus  or  at  its  margin ; 
or,  again,  wholly  within  the  anal  ring,  so  that  they  can  only  be  seen  by 
gently  opening  the  canal  with  tiie  fingers,  or  by  the  use  of  a  small  speculum 
or,  preferably,  Nelaton's  preputial  forcei)S  (see  Fig.  24,  p.  108).  They 
rarely  form  open  and  closely  circumscribed  ulcers,  but  usually  present  a 
thickened,  fissured,  and  ulcerated  surface  of  a  subacute  character,  devoid 
of  the  deep  redness  and  free  suppuration  of  simple  fissures.  They  are  of 
a  pale  rose  tint,  their  base  decidedly  indurated.  True  chancres,  seated  at 
the  anus  in  the  form  of  fissures,  which  they  often  assume,  have  hard,  pale 
margins  and  smooth,  light  red  surfaces.      Tlieir   bases   are   resistent  to 


CHANCRES    or    THE    FINGERS.  473 

the  touch,  and  they  are  usually  niucji  less  tender  than  simple  fissures — a 
point  of  considerable  importance  in  the  diagnosis,  which  may  also  be  aided 
by  their  slow  and  painless  evolution,  and,  sometimes,  by  the  early  develop- 
ment of  mucous  patches  in  their  neighborhood. 

Extra-genital  Chancres — Chancres  of  the  skin,  occurrin  in  other 
parts  than  the  genital  organs,  are  called  "extra-genital  chancres."  They 
may  appear  on  any  region  of  the  body,  but  they  are  most  commonly  found  on 
the  face,  the  neck,  the  arms,  forearms,  and  hyjiogastrium.  These  chancres 
begin  as  small,  coppery-red,  non-inflammatory  papules  which  may  be  scaly. 
They  extend  until  they  attain  a  diameter  of  half  an  inch  to  an  inch,  and 
an  elevation  of  about  a  line.  Their  margins  are  sharply  limited,  although 
there  is  not  much  induration.  The  scaly,  papular  condition  of  the  lesions 
is  seldom  found  in  regions  where  two  surfaces  are  in  coaptation.  We 
have  several  times  seen  it  upon  the  hypogastrium,  the  cheeks,  and  the 
neck.  The  degree  of  induration  is  sometimes  not  greater  than  that  of  an 
ordinary  papule;  in  other  cases  it  is  more  marked. 

Frequently  the  primary  lesion  begins  as  a  papule,  extends  slowly  and 
without  inflammation,  becomes  indurated,  elevated,  and  sharply  circum- 
scribed, and  finally  ulcerates.  In  some  cases  a  thin  greenish-brown  scab 
covers  the  lesion,  which  then  looks  like  an  ecthymatous  patch.  The  scab 
is  formed  of  pus  mingled  with  the  new  cells  thrown  off  from  the  surface  of 
the  ulcer.  In  case  of  its  absence  the  lesion  presents  a  raw  vascular  sur- 
face, of  about  a  line  in  elevation,  free  from  granulations,  and  sometimes 
covered  with  a  film  of  false  membrane  like  chamois  skin.  It  has  a  dense 
hardness  and  shows  no  reparative  tendency.  In  addition  to  the  history 
and  appearance  of  the  lesion,  we  find  chronic,  indolent  enlargement  of  the 
lymphatic  ganglia  in  anatomical  connection  with  the  part  affected. 

Chancres  of  the  Fingers. — Chancres  of  the  fingers  are  by  no  means 
infrequent,  and  are  especially  common  among  obstetricians,  surgeons,  and 
midwives.  They  may  be  seated  on  any  part  of  tiie  phalanges,  but  are, 
perhaps,  most  common  at  the  side  or  base  of  the  nail  or  at  its  free  margin. 
They  begin  either  as  a  ))imple,  as  a  pustule,  as  a  slight  excoriation,  or  as 
a  fissure.  They  first  attract  attention  as  a  "hang-nail"  which  Avill  not 
heal,  or  as  a  small  persistent  sore.  On  examination,  we  find  a  hard,  some- 
what elevated  mass  of  moderate  size,  which  has  a  deep  red,  perhaps  cop- 
pery, color.  Its  exulcerated  surface,  which  is  free  from  granulations, 
gives  forth  a  scanty  serous  secretion.  The  lateral  borders  of  the  nail 
may  be  somewhat  thickened,  and  its  free  margin  may  be  superficially 
ulcerated.  Tliis  tendency  of  the  chancre  to  be  confined  chiefly  to  the  soft 
parts  is  in  marked  contrast  with  the  morbid  condition  in  sypiiilitic  onychia. 
The  form  of  the  ulcer  is  very  irregular.  The  finger  itself  often  has  a 
bulbous  shape,  the  entire  distal  phalanx  being  involved  in  the  induration, 
which  is  always  extremely  chronic.  The  diagnosis  is  usually  confirmed 
by  enlargement  of  the  epitroclilear  and  axillary  ganglia;  it  is  iu  some 
cases  attended  by  moderate  lymphangitis.  The  fact  that  there  is  very 
slight  tendency  to  the  formation  of  abscesses  in  the  lymphatics  and  in  the 


474  INDICATIONS    FROM    SEAT    OF    CHANCRES. 

glands  is  important  in  the  diagnosis  of  syphilitic  chancres  of  the  fingers. 
On  account  of  their  exposed  situation  these  chancres  are  very  slow  to  heal. 
Numerous  instances  of  the  communication  of  syphilis  by  chancres  of  the 
fingers  have  occurred,  but  tlie  most  remarkable  is  the  case  reported  by 
Bardinet.  This  physician  was  appointed  to  investigate  an  epidemic  of 
sypliilis  which  occurred  in  the  town  of  Brive,  France.  He  ascertained  that 
those  affected  were  parturient  women  (and  their  husbands,  children,  and 
relatives)  who  liad  been  attended  in  confinement  by  a  certain  midwife, 
examination  of  whom  revealed  a  syphilitic  ulcer  near  the  margin  of  the 
nail  of  the  right  middle  finger.  She  afterwards  had  general  syphilitic 
manifestations.  Tliis  chancre  of  the  finger  had  been  in  an  ulcerated  con- 
dition for  about  six  months,  during  which  period  she  had  attended  fully 
fifty  women  in  confinement.  As  a  result,  nearly  one  hundred  persons 
became  infected  with  syphilis,  among  them  several  children  who  died. 
The  case  illustrates  the  great  importance  of  carefid  attention  to  chronic 
rebellious  ulcers  of  the  fingers  on  the  part  of  physicians  and  obstetricians. 

Chancres  of  the  Lip — Chancres  of  the  lips  are  quite  common,  and 
may  exist  in  the  form  of  a  diffuse  infiltration  or  of  a  fissure.  Those 
seated  near  the  vermilion  border  are  usually  much  larger  than  those  on 
the  inner  surfixce  of  the  lips;  Chancres  in  this  region  are  seldom  seen  by 
a  physician  until  they  have  reached  quite  a  large  size,  since  they  are  at 
first  regarded  as  cold-sores  or  cracks  of  the  lip.  They  begin  either  as 
sliglit,  often  painful,  excoriations,  or  as  fissures,  which  gradually  enlarge 
and  become  indurated.  Their  course  is  not  rapid,  a  month  or  six  weeks 
generally  elapsing  before  they  become  fully  developed.  When  seated  upon 
the  lower  lip,  as  they  more  commonly  are,  they  often  involve  its  whole 
thickness,  and  the  lip  becomes  converted  into  a  wedge-sha[)ed  mass  of 
induration  with  its  base  at  the  free  margin,  which  is  more  or  less  ulcerated. 
Such  a  chancre  usually  presents  a  ligneous  hardness.  The  lip  becomes 
everted  so  that  the  patient  is  unable  to  close  the  mouth.  The  surface  of 
the  ulcer  is  smooth,  and  emits  a  scanty  secretion.  In  other  cases  there 
exists  a  callous  fissure  with  reddish-gray  margins  and  a  deep  red  base. 
The  induration  is  usually  very  marked. 

Within  ten  days  after  the  appearance  of  the  chancre  the  submaxillary 
glands  become  swollen  and  indurated,  and  may  give  rise  to  much  dis- 
comfort and  pain. 

In  children  chancres  of  the  lip  are  sometimes  derived  from  lesions  on 
the  nip])le  of  the  nurse.  These  chancres  are  small,  round,  or  oval  in 
shape,  and  are  slightly  indurated.  They  may  readily  be  mistaken  for 
mucous  [jatches. 

AVhen  chancres  are  seated  at  the  labial  commissure,  tliey  are  divided 
into  two  portions,  separated  by  a  deep  ulcerated  fissure  at  the  angle  of  the 
mouth. 

Chancres  of  the  Buccal  Cavity Chancres  of  the  tongue  are  not 

frequent.     They  are  usually  seated  on  its  lateral  margins  near  the  tip. 


CnANCRES    IN    THE    FEMALE.  475 

They  consist  of  hard,  quite  sharply  circumscribed  nodules  of  the  size  of 
a  pea,  which  involve  the  deep  as  well  as  the  superficial  structures.  Their 
surface  is  flat  and  slightly  elevated  ;  it  has  a  dull  red  color,  is  smooth, 
raw,  and  highly  vascular.  In  some  cases  the  lesion  is  covered  with  a 
milky-white  film  and  resembles  a  mucous  patch. 

Chancres  of  the  tonsil  are  never  sharply  circumscribed.  They  are 
dark  red,  superficially  ulcerated  nodules  which  secrete  a  scanty  fluid. 
On  account  of  the  difficulty  in  examining  them,  it  is  not  easy  to  deter- 
mine their  density.  Tiieir  character  is  indicated  by  the  history  of  the 
case,  by  their  subacute  course,  by  the  absence  of  inflammatory  sylnptoms, 
and  the  enlargement  of  the  cervical  and  submaxillary  ganglia. 

Chancres  have  also  been  observed  upon  the  gums,  internal  surface  of 
the  cheeks,  the  palate,  and  the  walls  of  the  pharynx. 

Phagednena  is  a  rare  complication  of  the  buccal  chancre.  A  single 
instance  was  observed  at  Cullerier's  clinique,  in  which  irritant  applica- 
tions had  caused  the  ulcer  to  extend  until  it  involved  one-half  of  the  lower 
lip  and  the  inferior  half  of  the  cheek. ^ 

Chancres  in  the  Female These  are  in  general  similar  to  those 

occurring  in  the  male,  but  have  certain  features  which  should  be  clearly 
understood.  We  find  in  females,  as  in  males,  the  two  varieties,  the  indu- 
rated nodule  and  the  superficial  erosion,  although  their  appearances  are  less 
distinctive  than  in  the  male. 

Upon  the  labia  majora  either  variety  may  occur,  the  indurated  nodule 
perha[)S  being  more  frequent.  The  nodule  is  generally  quite  large,  the 
induration  sometimes  involving  the  whole  lip.  In  almost  all  cases  it  is 
deeply  seated  and  does  not  project  greatly  above  the  surrounding  level. 
In  some  cases  the  induration  is  cartilaginous  and  clearly  defined,  in  others 
it  is  less  marked  at  its  periphery.  The  induration  is  painless,  and  the 
superjacent  mucous  membrane  is  but  slightly  inflamed.  The  course  of  the 
indurated  nodule  is  very  chronic,  and  may  be  attended  by  hard  oedema  of 
adjacent  parts. 

The  chancrous  erosion  is  much  less  frequent  in  this  region.  It  begins 
as  a  small  red  spot,  which  increases  in  area  so  as  to  form  a  dark  coppei-y- 
red,  slightly  elevated  patch.  Its  surface  is  smooth  and  velvety,  being  free 
from  granulations  ;  its  elevation  above  the  surrounding  level  seldom  exceeds 
half  a  line;  its  margins  may  be  sharply  cut,  but  owing  to  the  tendency  to 
hyperemia  of  the  parts,  the  contour  of  the  initial  lesion  in  women  is  often 
obscured.  In  many  cases  we  find  the  true  parchment  induration,  while  in 
others  the  induration  may  b<;  so  slight  as  to  escape  recognition.  It  was 
formerly  claimed  that  syphilitic  chancres  in  women  were  free  from  indura- 
tion. On  the  contrary  these  lesionsare  in  reality  quite  constantly  indurated. 
Even  with  chancres  ui)on  the  i)repuce  the  induration  is  not  more  marked 
than  in  chancres  of  the  labia  majora.  The  (cdem  a  of  the  surrounding  parts 
is  certainly  greater  in  females  than  in  males,  and  vulvitis  is  not  uncommon 

'  BuzENETj  Du  chancro  do  la  bouche,  etc.,  Thfeso  do  Paris,  1858. 


476  INDICATIONS    FROM    SEAT    OF    CHANCRES. 

in  persons  of  uncleanly  habits.  Not  unfrequently  the  chancrous  erosion 
of  the  lal)ia,  es[)ecially  when  seated  on  the  cutaneous  surface  or  when  the 
lip  is  njuch  everted,  is  covered  by  a.  purulent  crust.  This  occurrence  is 
merely  accidental  and  due  to  exposure  of  the  ulcer,  allowing  its  secretions 
to  harden. 

Chancres  of  the  labia  minora  have  a  similar  history.  The  indurated 
chancres  are  usually  large,  often  involving  the  whole  of  one  lip  and  a  por- 
tion of  the  other.  The  clitoris  may  be  involved,  in  which  case  it  becomes 
hard  and  prominent,  and  according  to  the  simile  of  Fournier,  resembles  a 
ramrod.  The  clitoris  itself  and  its  sheath  become  much  condensed  and 
have  a  ligneous  hardness.  When  the  lower  part  of  the  labium  minus  is 
involved,  the  induration,  as  we  Have  often  observed,  may  extend  around 
to  the  opposite  lip,  forming  a  V-shaped  mass.  The  initial  lesion  of  the 
labia  minora  is  usually  less  clearly  defined  than  in  other  regions.  Tlie 
indurated  nodule  is  commonly  surrounded  by  more  or  less  hard  oedema. 

The  chancrous  erosion  of  tlie  labia  minora  is  usually  complicated  by 
vulvitis  and  is  often  multiple. 

C/tancres  of  the  fourcltefte  and  vestibule  are  very  interesting  and  often 
difficult  of  diagnosis,  both  because  they  are  not  readily  accessible  and  be- 
cause they  are  less  indurated.  The  lesions  are  rarely  circumscribed,  and 
rarely  present  the  typical  appearance  of  chancres.  We  find  rather  a  diffuse 
hardening  of  the  mucous  membrane,  which  has  a  dark  coppery-red  color, 
and  gives  forth  a  scanty  sero-pus,  which  may  be  augmented  by  secretions 
from  the  surrounding  parts.  The  parts  are  much  less  supple  than  normal, 
and  the  difficulty  in  thorough  examination  met  with  in  health  is  greatly 
increased.  The  vulvitis,  wliich  so  frequently  complicates  the  case,  rendei'S 
the  diagnosis  still  more  difficult.  Induration,  although  by  no  means  inva- 
riable, is  often  very  marked.  We  have  in  several  cases  found  the  four- 
chette  of  ligneous  hardness  and  the  orifice  of  the  vagina  rigid  and  resistent. 

AVe  know  nothing  of  chancres  of  the  vagina.  The  mucous  membrane 
of  tliat  canal  seems  always  to  escape  the  virus  or  perhaps  to  possess  an 
immunity  to  its  action. 

Cernatesco  has  studied  the  course  and  duration  of  chancres  and  vulvar 
syphilides  in  pregnant  women.  Of  the  former  he  collected  eleven  cases, 
in  whicli  the  chancres  were  on  the  vulva.  In  one  case,  the  duration  of 
the  sore  was  less  than  a  month,  and  in  the  other  ten  it  was  longer  than 
eight  weeks.  Three  lasted  from  four  and  a  half  to  eight  months.  He 
concludes  that,  under  the  influence  of  pregnancy,  the  duration  of  the  chan- 
cre is  notably  lengthened. 

Of  the  vulvar  syphilides  he  examined  thirty-three  cases,  which  he  di- 
vides into  two  groups:  1st,  those  which  he  was  able  to  follow  up  after 
delivery;  2d,  those  lost  to  view  prior  to  that  time.  These  lesions  were 
also  more  than  ordinarily  persistent  during  pregnancy,  and  in  some  instances 
disajjpeared  soon  after  delivery,  while  in  others,  they  were  equally  obsti- 
nate afterwards,  owing  to  the  bad  general  health  of  the  women. 

The  cause  of  tlie  persistency  of  the  above-named  lesions  is  due  to  a 
passive  congestion  of  the  genital  organs  rather  than  general  debility.     In 


CHANCRES    IN    THE    FEMALE.  47*7 

twenty-one  cases  of  pregnant  women  with  chancres  on  the  vulva,  there 
were  nine  of  abortion,  Cernatesco,  without  committing  himself,  advances 
the  hypothesis,  that  the  abortion  was  caused  by  the  lesions.  Admitting 
that  the  latter  may  act  as  irritants,  the  author  thinks  that  local  treatment 
should  not  be  too  active,  as  it  may  hasten  the  expulsion  of  the  foetus. 

We  would  simply  add  that  syphilitic  lesions,  and  especially  condylomata, 
of  the  vulva  in  pregnant  women,  often  present  a  most  remarkable  color 
resembling  that  of.  Port  wine,  undoubtedly  due  to  the  venous  congestion 
above  referred  to. 

Cliancres  of  the  Breast Chancres  of  the  breast,  or,  more  properly,  of 

the  nipple,  are  of  especial  importance  when  occurring  in  a  nursing  woman, 
in  view  of  the  danger  to  the  child  of  syphilitic  contagion.  These  chan- 
cres are  usually  derived  from  mucous  patches  in  the  mouths  of  nurslings, 
or  from  similar  lesions  in  the  mouths  of  men.  An  instance  of  the  latter 
mode  of  origin  occurred  not  long  since  in  our  own  experience. 

The  areola  as  well  as  the  nipple  may  be  invaded  by  these  lesions,  and 
less  commonly  the  breast  itself.  AYe  find  in  this  situation  the  chancrous 
erosion,  the  ecthymatous  chancre,  and  the  indurated  fissure. 

The  chancrous  erosion  is  commonly  found  upon  the  areola.  It  consists 
of  a  sharply  marginated,  slightly  elevated  patch  ;  its  surface  is  flat,  smooth, 
and  shining ;  its  contour  may  be  round  or  oval ;  its  color  deep  coppery- 
red.  The  slight  induration  at  first  detected  by  the  finger,  gradually  be- 
comes well  marked.  This  lesion  presents  a  similar  appearance  when  it 
involves  the  nipple,  but  it  is  then  usually  more  indurated.  Such  chan- 
cres may  be  single  or  multiple — two  being  the  ordinary  number — although 
we  have  seen  as  many  as  five.     There  is  nothing  peculiar  in  their  course. 

The  ecthymatous  chancre  may  occur  on  the  ni{)ple  or  on  the  areola ; 
more  commonly  on  the  former.  It  forms  a  hard,  painless,  circumscribed 
nodule,  which  may  involve  all  or  part  of  the  nipple,  or  a  portion  of  the 
areola.  A  dark-green,  uneven  crust,  which  is  slightly  adherent,  conceals 
a  smooth,  grayish-i-ed,  eroded  surface.  The  ulcer  becomes  thus  encrusted 
in  consequence  of  the  absence  of  moisture.  Were  the  nipple  subjected  to 
suction  and  moisture,  the  secretion  would  cease  to  harden  and  there  would 
be  simply  an  exulcerated  chancre.  The  name  ecthymatous  chancre,  how- 
ever, may  well  be  retained,  since  it  suggests  appearances  necessary  to  be 
borne  in  mind.  The  induration  may  be  extreme  or  moderate,  and  varies 
in  extent.  In  some  cases  both  the  whole  nipple  and  the  areola  arc  in- 
volved in  the  induration. 

The  indurated  fissure  of  the  nipple  is  merely  an  induration  traversed 
by  fissures  which  have  a  reddish-gray  color.  The  fissures  may  be  superfi- 
cial, or  they  may  be  extensive,  invading  tlie  areola.  Tliey  may  exude  a 
more  or  less  purulent  secretion,  and  indeed  the  whole  lesion  may  become 
encrusted.  These  lesions  are  slowly  developed  and  are  attended  by 
scarcely  any  pain  even  in  the  fissured  form,  features  of  much  diagnostic 
value.  They  are  seldom  inflammatory,  but  are  usually  insidious  and  sub- 
acute. In  some  cases  the  sebaceous  glauds  of  tlie  areola  are  enlarged  and 
prominent.     In  all  cases  the  axillary  glands  are  eidarged,  and  in  most  the 


478  INDICATIONS    FROM    SEAT    OF    CHANCRES. 

ganglia  at  tlie  upper  margin  of  the  great  pectoral  muscle  are  indui-ated, 
the  latter  being  recognized  with  difficulty  in  lat  persons. 

In  securing  wet-nurses,  physicians  cannot  be  too  careful  in  examining 
for  mammary  chancres.  A  woman  having  a  sore  in  the  least  degree  sus- 
picious slioukl  never  be  allowed  to  nurse  a  healthy  child.  Careful  inquiry 
should  be  made  as  to  the  condition  and  history  of  children  nursed  within 
at  least  tlie  last  montli.  A  woman  who  has  nursed  a  child  with  sore 
mouth,  eruptions,  marasmus,  or  osseous  lesions,  should  be  suspended  for 
from  four  to  six  weeks,  during  which  time,  if  she  has  been  infected  with 
syphilis,  the  initial  lesion  will  appear  on  her  breast. 

Chancres  of  the  Uterus Chancres  of  the  uterus  have  been  carefully 

studied  within  the  past  ten  years  by  Fournier,  Schwartz,  and  Jullien. 
Tiiey  may  be  seated  on  one  lip  of  tiie  cervix,  generally  the  lower  one,  or 
within  the  neck.  There  is  generally  but  one  which  begins  as  a  bright 
red  erosion. of  the  mucous  membrane.  It  gradually  extends  and  becomes 
somewhat  elevated,  and  when  fully  developed  looks  like  a  papule.  In 
some  cases  there  is  no  perceptible  elevation  of  the  ulcer,  but  its  margins 
are  circumscribed  and  are  frequently  surrounded  by  a  dark-red  areola. 
The  floor  of  the  chancre  is  smooth,  of  a  grayish-  or  yellowish-red  color, 
or  it  may  be  covered  by  a  false  membrane  like  chamois  skin.  The  lesion, 
Avhen  seated  on  the  outer  surface  of  the  os,  is  rounded  or  oval,  and  about 
the  size  of  an  almond  ;  within  the  os  it  may  be  limited  to  one  segment  or 
mny  surround  the  opening  in  the  form  of  a  ring.  Its  secretion  is  scanty 
and  viscid.  The  degi'ee  of  induration  varies,  being  limited  to  the  neigh- 
borhood of  the  chancre,  or  being  diffused. 

In  a  case  of  prolapsus  with  uterine  chancre,  seen  by  Ricord,  the  os  was 
enlarged  and  very  dense,  and  in  other  instances  the  wiiole  neck  has  been 
found  involved  in  the  induration. 

The  course  of  these  chancres  is  indolent  and  painless.  Fournier  states 
that  in  five  cases  of  chancre  of  the  os  uteri  he  observed  vulvar  and  peri- 
vulvar  herpes,  and  he  thinks  that  the  presence  of  these  lesions  should 
always  suggest  the  possible  syphilitic  character  of  the  uterine  ulcer.  He 
also  calls  attention  to  the  fact  that  uterine  chancres  often  disappear  within 
a  few  days,  leaving  no  trace.  There  is  generally  no  enlargement  of  the 
inguinal  ganglia  during  the  course  of  a  uterine  chancre. 


INDURATION    OP    THE    GANGLIA.  479 


CHAPTER    V. 

INDUPwVTION    OF    THE    GANGLIA    AND    OF    THE 
LYMPHATICS. 

As  already  mentioned,  the  induration  of  the  base  of  a  chancre  has  been 
su[)posed  to  be  most  developed  in  regions  most  copiously  supplied  with 
lym[)hatic  vessels,  and  was  consequently  regarded  by  Ricord  and  others  as 
consisting  essentially  in  a  specific  lymphitis.  But  even  if  this  supposition 
be  incorrect,  it  is  certainly  true  that  we  find  a  condition  of  the  lymphatic 
vessels  and  ganglia  in  anatomical  connection  with  a  chancre,  closely  re- 
sembling the  induration  of  its  base,  and  of  even  greater  diagnostic  value 
than  the  latter.  We  may,  therefore,  regard  this  affection  as  an  oflshoot 
or  prolongation  of  the  induration  of  the  base  of  the  initial  lesion  of  syphilis 
previously  described. 

Of  the  two — induration  of  the  ganglia  and  induration  of  the  lymphatic 
vessels — the  former  is  by  far  the  more  frequent,  just  as  we  find  adenitis, 
rather  than  lympliitis,  the  more  constant  attendant  upon  a  chancroid. 

Induration  of  the  Ganglia.     (Syphilitic  Bubo.) 

I  have  already  stated  the  reasons  which  led  us  to  exclude  this  affection 
from  under  the  head  of  "buboes,"  but  if  it  still  be  called  a  "bubo,"  the 
adjective  "syphilitic"  belongs  to  it  exclusively,  and  is  so  applied  by  recent 
French  writers. 

Constancy Does   induration   of  the   fjanglia  necessarily   attend  a 

cliancre^ 

Rollet,  in  his  own  clinical  experience,  states  that  its  absence  is  a  "rare 
exception." 

Kicord  regards  induration  of  the  ganglia  as  '■\fatale"  '■'■  ohVu/tef  "it 
follows  a  chancre  as  a  sliadow  follows  a  body;"  "never  a  chancre  without 
induration  of  the  ganglia  may  be  boldly  asserted  as  a  pathological  law." 

Fournier  says:  "With  very  rare  exceptions,  it  '\s, -a  constant  symptom 
of  primary  syphilitic  infection."  The  testimony  of  most  other  modern 
observers  is  the  same. 

For  my  own  part  I  have  never  met  with  a  chancre  which  was  not 
attended  by  induration  of  the  neighboring  lym[)hatic  ganglia,  although 
this  induration  has  been  doubtful  for  a  time,  in  a  few  instances,  especially 
in  strumous  subjects,  yr  has  been  masked  by  the  occurrence  of  acute  in- 
flammation. I  regard  it  as  by  far  the  more  valuable  symptom  of  a  chancre 
than  induration  of  tlie  base  of  the  ulcer  itself,  since  it  is  less  likely  to  be 


480  INDURATION    OF    THE    GANGLIA    AND    LYMPHATICS. 

counterfeited  by  extraneous  influences,  and  is  even  more  constant  and 
persistent. 

Yet  it  would  afjpear  that  this,  like  every  other  isolated  symptom  of 
syphilitic  infection,  may  in  very  rare  instances  be  wanting.  In  the  twenty- 
six  cases  of  artificial  inoculation  of  the  syphilitic  virus  upon  persons  pre- 
viously free  from  syphilis,  collected  by  RoUet,  induration  of  the  ganglia  is 
mentioned  in  only  twenty,  but  we  are  left  in  doubt  whether  this  was  due 
to  its  absence  or  to  the  imperfection  of  the  observation. 

Bassereau  carefully  examined  the  condition  of  the  ganglia  in  three 
hundred  and  eighty  cases  of  chancre,  the  diagnos^is  of  which  was  confirmed 
bv  the  evolution  of  secondary  symptoms,  and  found  induration  in  three 
iiundred  and  fifty-five.  But  here,  again,  the  question  may  arise  whether, 
in  tiie  twenty-five  exceptional  cases,  induration  had  not  previously  existed 
but  had  disappeared  at  the  time  of  the  examination. 

Fournier.  reports  2Go  cases  of  chancre,  of  which  the  ganglia  were  in- 
volved in  2C)0,  but  in  3  cases  only  was  the  absence  of  induration  from  the 
outset  certain. 

The  instances  in  which  this  attendant  upon  a  chancre  is  likely  to  be 
wantinof  or  of  doubtful  recognition  may  be  classified  as  follows: — 

I.  Strumous  subjects.  I  have  met  with  a  number  of  patients  of  strumous 
habit  who  stoutly  asserted  that  the  enlargement  of  the  inguinal  ganglia 
had  existed  long  before  the  sore  upon  the  penis,  and  their  evident  scrofu- 
lous diathesis  has  added  weight  to  their  statements,  and  rendered  the 
diagnosis  for  a  time  doubtful. 

II.  In  cori>ulent  persons  the  mass  of  adi{)Ose  tissue  may  render  it  diffi- 
cult to  recognize  the  condition  of  the  ganglia  by  means  of  external  palpa- 
tion. Ricord,  it  appears,  would  go  one  step  further  and  regard  corpulent 
subjects  as  less  prone  than  others  to  exhibit  this  lesion  in  its  full  develop- 
ment. He  says:  "The  ganglionic  system  is  usually  in  the  inverse  ratio, 
in  respect  to  its  development,  to  that  of  the  adipose  system.  In  very  fat 
persons  the  ganglia  are  small;  in  connection  with  a  true  chancre  they  .are 
often  only  slightly  enlarged ;  sometimes,  though  rarely,  they  are  not  per- 
ceptible."    (Oral  communication  to  M.  Fournier.) 

III.  Again,  Ricord  and  Fournier  both  assert  that  if  a  chancre  be 
attacked  by  phagedicna,  the  ganglia  will  remain  unaffected.  "Pliageda^na 
would  appear  to  be  one  of  the  conditions  wliich  prevent  syphilis  from 
affecting  the  ganglia."  In  my  own  experience,  phagedtena  has  attacked 
a  chancre  in  most  cases,  after  induration  of  the  ganglia  had  already 
appeared,  so  that  I  am  unable  to  confirm  this  statement. 

IV.  According  to  Fournier,  "  in  very  rare  instances,"  induration  of 
the  ganglia  is  wanting  "in  connection  with  a  chancre  in  the  form  of  a 
superficial  erosion,  or  an  exulcerated  papule,  presenting  a  scarcely  per- 
ceptible or  doubtful  induration."  For  my  own  part,  in  such  instances  I 
have  always  referred  to  the  ganglia  to  confirm  my  diagnosis,  and  have 
never  known  them  to  fail  me.  , 

V.  Finally,  we  have  those  cases,  studied  especially  by  Diday,  and  en- 
dorsed to  this  extent  by  Ricord,  in  which  the   rare  inoculation  of  the 


SEAT.  481 

syi>hilitic  virus  upon  persons  previously  infected  produces  only  a  local 
sore,  without  reaction  upon  the  ganglia  or  the  system  at  large.  I  have 
nothing  to  offer  on  this  point,  because  I  have  never  met  with  such  cases 
well  established. 

The  absence  of  induration  of  the  base  of  a  chancre  and  of  its  neigli- 
boi'ing  ganglia  may,  in  rare  instances,  be  admitted,  without  materially 
detracting  from  the  value  set  upon  their  diagnostic  and  prognostic 
indications;  for  why  should  absolute  constancy  be  expected  in  syphilitic 
symptoms  any  more  than  in  those  of  other  diseases,  and  in  the  whole 
range  of  pathology  it  would  be  difficult  to  find  two  which  are  more  uni- 
formly present  than  these. 

Seat — As  already  stated,  the  ganglia  affected  are  those  in  direct 
anatomical  connection  with  the  initial  lesion  or  chancre.  Since  a  chancre 
is  most  frequently  situated  upon  the  genital  organs,  induration  of  the 
ganglia  is  commonly  found  in  the  groins.  Chancres  of  the  interior  of  the 
urethra  in  both  sexes,  of  the  perineum,  of  the  anus,  of  the  cervix  uteri, 
of  the  buttocks,  of  the  lower  portion  of  the  abdomen,  and  of  any  point  of 
the  lower  extremities,  will  likewise  manifest  their  presence  by  induration 
of  the  inguinal  ganglia.  According  to  Ricord,  when  the  chancre  is 
situated  at  the  anus,  it  is  the  external  portion  of  the  inguinal  group  near 
the  anterior  su[)erior  spine  of  the  ileum,  that  is  involved. 

With  chancres  upon  the  fingers  the  situation  of  the  indurated  ganglia 
varies.  In  one  case  of  a  chancre  upon  the  forefinger  I  found  a  well-marked 
indurated  ganglion  in  the  web  between  the  forefinger  and  thumb.  More 
frequently,  in  these  cases,  the  ganglion  on  the  internal  side  of  the  elbow,, 
or  those  in  the  axilla  are  involved.  Again,  ganglia  between  the  points 
mentioned — the  hand  and  elbow,  or  the  elbow  and  axilla — may  become 
indurated.  Thus,  in  a  case  under  my  care,  the  chancre  was  upon  the 
thumb,  and  the  ganglionic  induration  showed  itself  at  the  elbow  (epi- 
trochlear  gland),  and  also  in  a  gland  situated  about  half  way  between  the 
elbow  and  axilla  on  the  inner  side  of  the  arm.  Chancres  of  the  breast 
also  affect  the  axillary  ganglia. 

Chancres  upon  the  lips,  both  upper  and  lower,  upon  the  tongue,  and 
upon  the  chin,  cause  induration  of  the  submaxillary  ganglia  ;  those  upon 
the  eyelids,  induration  of  a  ganglion  situated  directly  in  front  of  the  ear. 
Fournier  mentions  a  case  of  a  chancre  occupying  the  palatine  arch,,  in 
which  a  large  ganglion  was  present  in  the  thickness  of  the  cheek  ;  also 
another  case  in  which  infection  was  "very  certainly"  the  result  of  cathe- 
terization of  the  Eustachian  tube,  and  in  which  there  were  two  voluminous 
ganglia  in  tlie  parotid  region,  one  directly  below  the  ear  and  tin;  other 
somewhat  beneath  it  imder  the  ramus  of  the  jaw. 

Thus  the  situation  of  ganglionic  induration  points  to  the  ap[)n)xiniate 
seat  of  a  chancre,  even  after  the  latter  has  disappeared,  and  mny  be  of 
essential  service  in  unravelling  the  liistory  of  obscure  venereal  cases.  For 
instance,  in  the  spring  and  summer  of  lb()3,  a  young  man  had  two  attacks 
of  what  was  apparently  simple  gonorrhoia.  In  the  autumn  he  applied  to 
31 


482  INDURATION    OF    THE    GANGLIA    AND    LYMPHATICS. 

mc  with  syphilitic  iritis,  alopecia,  acne  capitis,  and  post-cervical  engorge- 
ment, and  there  coidd  be  no  doubt  that  he  had  had  a  chancre  somewhere 
near  the  genitals,  although  he  was  quite  unconscious  of  the  fact,  since  each 
groin  presented  the  characteristic  indurated  pleiad.  One  of  his  attacks 
of  gonorrluca  was  probably  complicated  with  a  urethral  chancre. 

Again,  a  young  j)hysician  called  upon  me  with  well  marked  syphilitic 
papuhv,  which  he  attributed  to  contagion  incurred  in  attendance  upon  a 
midwifery  case  ^'■jive  tveeks  before,"  and  he  showed  me  a  scar  upon  the 
forefinger  M'hich  he  said  was  the  seat  of  the  chancre,  at  the  same  time 
denying  any  other  exposure.  It  was  so  improbable  that  his  eruption  had 
been  developed  thus  rapidly,  that  1  examined  his  groins,  and  the  indura- 
tion of  the  ganglia  nailed  the  lie,  which  he  subsequently  confessed. 

The  following  table,  borrowed  from  Fournier,  gives  at  a  glance  the 
situation  of  the  indurated  ganglia,  according  to  the  varying  seat  of  the 
chancre : — ■' 

Seat  op  the  Chancre.  Cokresponding  Bubo  in  the — 

Chancres  of  the  genital  organs,  i.  e., 
of  the  penis,  scrotum,  the  labia  majora 
and  minora,  the  fourchette,  the  meatus 
urinarius,  the  urethra,  the  entrance  of 
tlie  vagina,  etc.  Inguinal  ganglia. 

Peri-genital  chancres  (those  of  the 
perin;enm,  the  genito-crural  folds,  the 
mons  veneris,  the  thighs,  the  buttocks, 
etc.).  Inguinal  ganglia. 

Chancres  of  the  anus  and  the  margin 
■of  the  anus.  Inguinal  ganglia. 

Chancres  of  the  lii)s  and  of  the  chin.  The  submaxillary  ganglia. 

Chancres  of  the  tongue.  The  sub-hyoidian  ganglia. 

Cliancres  of  the  eyelids.  The  preauricular  ganglia. 

Chancres  of  the  fingers.  The    epi-trochlear   and   the   axillary 

ganglia. 

Chancres  of  tlie  arm.  The  axillary  ganglion. 

Chancres  of  the  breast.  The  axillary  ganglia  and  sometimes 

the  sub-pectoral  ganglia. 

Chancres  of  tlie  uterine  neck.  Theoretically     the     pelvic     ganglia. 

Generally  nothing  is  found  in  the  groins. 
Exceptionally  an  inguinal  bubo. 

TiMK  OF  AiTEAKANCE — According  to  Rollct,  in  cases  of  artificial 
syphilitic  inoculation,  induration  of  the  ganglia  appears  on  an  average 
eleven  days  after  the  comnioicement  of  the  chancre.  In  practice,  how- 
ever, we  find  it  earlier,  and  usually  at  the  same  time  as  the  induration  of 
the  Ijase  of  the  sore.  In  exceptional  instances,  its  development  is  delayed, 
but,  according  to  llicord,  never  beyond  a  fortnight.  In  some  doubtful 
cases  of  venereal  ulcers  I  have  been  obliged  to  defer  my  diagnosis  for  a 
week  or  ten  days  until  induration  of  the  ganglia  became  well  marked  and 
removed  all  doubt.  Fournier  refers  to  a  case,  which  he  says  has  been 
iniifjue  iii  his  experience,  of  the  induration  not  showing  itself  until  the 
twenty-seventh  day  after  the  appearance  of  the  chancre. 


COURSE    AND    TERMINATION.  483 

Symptoms — Induration  of  the  inguinal  ganglia  may  affect  one  or  both 
sides ;  in  the  former  case  it  is  usually  the  side  upon  which  the  chancre  it- 
self is  situated,  although  occasionally  this  rule  is  reversed,  as  witli  buboes 
attendant  upon  a  chancroid. 

AVherever,  as  in  tlie  groin,  a  number  of  ganglia  form  a  group,  most  of 
them,  at  least,  are  usually  involved,  but  to  an  unequal  extent.  A  "  pleiad," 
as  it  has  been  called  by  Ricord,  of  small  olive-shaped  or  globular  tumors 
is  felt,  cartihiginous  in  hardness,  freely  movable  upon  each  other  and  the 
surrounding  tissues,  and  without  attachment  to  the  overlying  integument. 
One  is  commonly  developed  more  tlian  the  rest,  and  attains  about  the 
size  of  an  almond  ;  the  others  as  large  as  a  bean  or  cherry,  surround  it  like 
satellites. 

There  are  no  symptoms  of  acute  inflammation.  The  change  has  taken 
place  insidiously  and  often  without  the  patient  knowing  it.  The  skin  is 
not  altered  either  in  color  or  temperature.  Firm  pressure  sometimes 
reveals  slight  tenderness,  but  rarely  excites  severe  pain ;  and  motion  is 
usually  not  impeded.  Indolence  is  one  of  the  chief  characteristics  of  a 
"syphilitic  bubo." 

Less  frequently,  only  a  single  tumor  is  felt  in  the  groin,  varying  in  size 
and  shape  in  different  cases  :  sometimes  it  may  be  compared  to  a  good- 
sized  plum,  while  at  other  times  it  is  elongated,  about  the  thickness  of  the 
finger,  and  corresponds  in  direction  to  the  inguinal  fold.  In  several  in- 
stances, as  the  tumor  subsided,  I  have  found  it  resolve  itself  into  several, 
sliowing  that  it  was  composed  of  a  number  of  coherent  ganglia,  and  this 
fact  has  been  demonstrated  by  Bassereau  in  post-mortem  examination. 

When  a  chancre  is  situated  at  a  distance  from  any  group  of  ganglia  as 
upon  the  fingers  or  face,  only  one  or  tvvo  of  these  bodies  are  usually  in- 
volved. 

Course  and  Termination Induration  of  the  ganglia  usually  reaches 

its  full  development  in  the  course  of  a  week  or  fortnight.  If  mercury  be 
given  for  the  primary  sore,  it  may  somewhat  diminish  for  a  time,  but 
commonly  undergoes  a  recandescence  upon  the  evolution  of  secondary 
synn)toms,  resembling  in  this  res[)ect  the  induration  of  the  chancre.  It  is 
usually  more  persistent  than  the  latter,  but  its  ultimate  duration  varies  in 
different  cases,  from  several  weeks  to  five  or  six  months,  or  even  longer. 
Ricord  states  tliat  he  has  found  unequivocal  traces  of  it  several  years  after 
infection  in  exceptional  cases. 

Resolution  without  suppuration  is  almost  the  constant  termination  of 
syphilitic  induration  of  the  ganglia,  but  to  deny  tliat  suppuration  never 
takes  place  as  some  authors  have  done  is  to  assert  tiiat  induration  protects 
the  ganglia  from  every  cause  of  acute  inflammation,  whicli  is  evidently 
absurd.  Since  the  indurated  ganglia  are  not  in  a  healthy  condition,  the 
only  wonder  is  that  they  do  not  more  frequently  inflame  and  suppurate, 
but  the  rarity  of  this  termination  is  now  well  demonstrated. 

Bassereau  found  only  sixteen  cases  of  suppurating  buboes  in  3H3  cases 
of  syphilis. 


484  INDURATION    OF    THE    GANGLIA    AND    LYMPHATICS. 

In  the  large  number  of  true  chancres  treated  by  Ricord  at  the  Hopital 
du  Midi,  and  in  its  out-door  department,  in  the  year  1856,  there  were  only 
three  which  were  accompanied  by  suppurating  buboes. 

Kollet  has  found  17  cases  of  suj)puration  in  320,  at  the  Antiquaille  Hos- 
pital; Fournier  only  2  in  205.  In  speaking  of  the  rarity  of  suppuration 
in  this  form  of  adeno[)athy,  it  is  of  course  understood  that  no  chancroid 
coexists  in  the  neighborhood  or  has  been  imjdanted  upon  the  site  of  the 
chancre  itself,  constituting  the  so-called  "  mixed  chancre,"  and  capable  of 
exerting  its  own  peculiar  influence  upon  the  glands. 

The  causes  which  may  favor  the  occurrence  of  su[)puration  in  indu- 
rated ganglia  are  the  same  as  those  mentioned  when  speaking  of  buboes, 
but  the  most  frequent  is  a  strumous  diathesis  or  general  debility.  In  the 
following  case  several  influences  probably  had  a  part : — 

B.  belonged  to  a  strumous  family.  His  sister,  aged  17,  had  been  afflicted 
with  an  aggravated  form  of  chronic  eczema  since  early  infancy.  His 
brother,  after  hardship  and  exposure  upon  a  wreck,  was  confined  to  his  bed 
for  six  months  with  suppuration  of  the  inguinal  glands.  B.,  who  had 
always  enjoyed  good  health,  contracted  a  chancre  in  June,  1859,  followed 
by  glandular  induration.  Syphilitic  erythema  appeared  in  September, 
when  the  glands,  which  until  then  had  been  indolent,  became  inflamed, 
suppurated,  and  remained  open  six  weeks.  The  general  symptoms  proved 
to  be  very  obstinate,  and  he  was  still  under  treatment  in  July,  18G0, 
when,  after  violent  exercise  at  leap-frog,  another  abscess  formed  in  the 
same  groin. 

It  will  be  noticed  in  this  case,  that  the  inguinal  glands  remained  in  a 
quiescent  state  for  nearly  three  months  after  the  healing  of  the  chancre, 
and  their  suj)puration  at  the  end  of  this  time  can  only  be  ascribed  to  the 
strumous  diathesis  of  the  patient,  and  also,  in  a  measure,  to  the  febrile 
excitement  preceding  the  syphilitic  eruption. 

The  value  of  suppuration  of  the  glands  in  a  suspected  case  of  syphilis 
as  an  element  of  diagnosis  is  a  question  of  considerable  practical  import- 
ance. A  patient  with  general  symptoms  of  a  doubtful  character  seeks 
advice  of  a  surgeon,  who  learns  that  several  years  ago  he  had  a  venereal 
sore,  but  can  obtain  no  accurate  description  of  its  symptoms.  On  further 
inquiry  he  also  ascertains  that  there  was  tumefaction  of  the  glands  in  the 
groin,  and  the  patient  rarely  fails  to  remember  whether  they  suppurated  or 
not — a  fact  which  may  also  be  determined  in  most  cases  by  the  presence  or 
absence  of  a  cicatrix.  What  liglit  will  this  investigation  throw  upon  the 
nature  of  the  sore  ?  If  the  description  above  given  be  correct,  the  fact 
that  suppuration  took  place  will  Javor  but  will  not  absolutely  prove  the 
supposition  that  the  sore  was  a  chancroid.  It  is  a  common  but  not  in- 
variable rule  that  general  syphilis  does  not  follow  an  open  bubo. 

In  the  rare  instances  in  which  suppuration  takes  place  the  pus  is  never 
auto-inoculable  like  that  of  the  virulent  bubo ;  whether  it  contains  the 
syphilitic  virus  and  that  its  inoculation  upon  a  person  free  from  syphilis 
would  produce  a  chancre,  is  a  question  which  has  never  been  solved  by 
experiment. 


INDURATION    OF    THE    LYMPHATICS.  485 

Diagnosis Induration  of  the  ganglia  is  most  liable  to  be  confounded 

with  strumous  engorgement  ;  the  history  of  the  case  and  the  concomitant 
symptoms  must  decide  the  diagnosis. 

Only  great  stupidity  could  lead  the  attending  physician  to  regard  cancer- 
ous degeneration  of  the  inguinal  glands  with  an  ulcerated  cancerous  tumor 
of  the  glans  penis  as  syphilitic,  althougli  this  has  actually  occurred  in  a 
case  to  which  I  was  called  in  consultation. 

Induration  of  the  ganglia  is  so  distinct  from  the  simple  inflammatory 
and  virulent  bubo  that  I  need  not  dwell  upon  their  points  of  difference. 

Induration  of  the  Lymphatics. 

As  both  the  simple  and  virulent  bubo  have  their  occasional  attendants 
in  simple  and  virulent  lymphangitis,  so  has  glandular  induration  its  ac- 
companying induration  of  the  Ij^mphatics,  a  more  constant  companion, 
though  not  invariably  present,  than  either  of  the  former. 

Specific  engorgement  of  the  lymphatics  is  dependent  upon  changes  in 
the  walls  of  these  vessels  identical  with  those  which  occasion'  induration 
of  the  base  of  the  chancre  and  of  the  ganglia,  and  is  characterized  by  the 
same  three  important  symptoms,  viz.,  induration,  absence  of  inflammation, 
and  persistency. 

The  indurated  vessel  feels  like  a  hard  cord  running  from  the  neighbor- 
hood of  the  chancre  towards  the  pubes  along  the  upper  surface  of  the 
penis  in  the  course  of  the  dorsal  vein  and  artery,  or,  in  a  few  instances,  it 
occupies  the  side  of  this  organ.  It  is  generally  single,  but  sometimes 
multiple;  of  the  size  of  a  crow  or  goose-quill;  in  some  cases  of  uniform 
diameter,  when  it  communicates  to  the  fingers  a  sensation  like  that  of  the 
vas  deferens,  while  in  others  it  is  swollen  at  regular  intervals  like  a  neck- 
lace, or  is,  as  botanists  would  say,  moniliform.  The  distal  extremity  arises 
in  the  induration  surrounding  the  chancre,  and  the  cord  can  generally  be 
traced  for  two  or  three  inches  towards  the  pubes,  sometimes  to  the  base  of 
this  prominence,  but  rarely  as  far  as  the  indurated  ganglia  in  the  groin. 

Induration  of  the  lymph.atics  is  most  frequently  observed  upon  the  penis, 
but  is  not  limited  to  tliis  region,  Bassereau  relates  a  case  of  chancre  upon 
the  cheek,  in  which  a  hard  cord  could  be  traced  from  the  indurated  base 
of  the  sore  to  an  indurated  ganglion  beneath  the  angle  of  the  jaw. 

Induration  of  the  lymphatics  ai)pears  about  the  same  time  and  in  the 
same  manner  as  that  of  tlie  base  of  the  chancre,  and  the  two  generally 
correspond  in  degree  of  development.  As  already  stated,  the  former  is 
less  constant  than  the  latter,  but  if  sought  for  may  be  found  in  a  large 
proportion  of  cases. 

Induration  of  the  lymphatics  usually  undergoes  resolution  about  the 
same  time  as  that  of  the  base  of  the  sore;  but  in  a  few  rare  instances.it 
becomes  inflamed  and  terminates  in  suppuration,  when  fistulous  openings 
may  form  along  the  course  of  the  vessel.  Bassereau  met  witii  three  cases 
in  wiiich  the  indiu'ation  of  the  chancre  took  on  inflammatory  action  and 
was  transformed  into  a  plilcgmonous  tumor,  the  cavity  of  whicli  was  found 


486  INDURATION    OF    THE    GANGLIA    AND    LYMPHATICS. 

to  communicate  Avith  the  interior  of  an  hypertropbied  lympliatic,  through 
which  a  probe  could  be  passed  up  to  the  pubes.  In  one  instance  he  was 
able  to  make  a  post-mortem  examination,  the  patient  having  died  of  an 
intercurrent  acute  disease.  The  dorsal  vein  and  artery  were  found  to  be 
intact,  and  the  fistulous  canal  evidently  consisted  of  an  hypertro[)liied  lym- 
phatic with  hard  and  thickened  walls,  which  could  be  traced  from  the 
induration  of  the  chancre  to  the  right  inguinal  ganglia. 

Induration  of  the  lymphatics  may  readily  be  distinguished  with  care 
from  the  dorsal  vein  and  artery.  It  is  more  liable  to  be  confounded  with 
simple  or  virulent  lymphangitis.  The  diagnostic  symptoms  have  akeady 
been  given  when  describing  the  latter. 

This  symptom  of  a  chancre  has  the  same  prognostic  signification  as  the 
induration  of  the  base  of  the  sore  and  the  inguinal  ganglia,  and  denotes 
that  the  constitution  is  ali'eady  infected  and  that  general  syphilis  will  soon 
make  its  appearance. 

Treatment  of  Induration  of  the  Ganglia  and  Lymphatics. 

Uncomplicated  cases  of  indurated  ganglia  require  absolutely  no  local 
treatment  wliatever.  When,  tlierefore,  an  otherwise  healtliy  patient  with 
a  chancre  and  induration  of  the  neighboring  ganglia  anxiously  inquires 
whether  he  is  likely  to  be  laid  up  with  a  suppurating  bubo,  he  may  be 
assured  that  there  is  no  danger  unless  he  commit  some  great  imprudence. 
Under  the  mercurial  treatment  required  by  the  constitutional  infection 
which  has  already  taken  place,  the  indurated  ganglia  gradually  diminish 
in  size  and  lose  the  slight  degree  of  tenderness  which  they  possessed.  In 
the  excej)tional  cases  of  su|)i)ui-ation  the  treatment  is  the  same  as  for'in- 
flammatory  buboes,  thougli  generally  less  active. 

The  same  remarks  ai)i>ly  to  the  treatment  of  induration  of  the  lymphatics. 


STATE    OF    THE    BLOOD.  487 


CHAPTER    VI. 

STATE   OF   THE   BLOOD;     SYPHILITIC   FEVER;     AF- 
FECTIONS  OF   THE   LYMPHATIC   GANGLIA. 

State  op  the  Blood. 

A  SERIES  of  analyses  of  the  blood  performed  by  M.  Grassi  under  the 
direction  of  Ricord,  shows  that  this  fluid  undergoes  a  material  change  in 
the  early  stage  of  syphilis,  consisting  chiefly  in  a  diminution  of  the  blood 
corpuscles,  which,  on  an  average  amounted  to  a  loss  of  one-seventh,  and, 
in  one  instance,  to  one-half  of  the  usual  number.  Under  the  administra- 
tion of  iodide  of  potassium  the  number  of  the  blood  corpuscles  was  found 
to  increase ;  but  no  improvement  took  place  from  the  use  of  mercury. 
This  chloro-ana^mia  is  confined  to  the  early  stage  of  syphilis;  the  blood 
soon  recovers  its  normal  composition  and  retains  it  throughout  the  whole 
course  of  the  disease  unless  syphilitic  cachexia  supervenes.  Though 
foreign  to  our  present  subject,  it  may  be  mentioned  incidentally,  that  the 
blood  of  persons  affected  Avith  chancroids  was  sliown  in  a  second  series  of 
analyses  by  Ricord  and  Grassi  to  remain  unchanged ;  and  thus  these  ex- 
periments, which  were  performed  before  the  question  of  the  duality  of  the 
chancrous  virus  had  been  mooted,  are  confirmatory  of  the  distinction 
which  is  now  recognized  between  the  chancroid  and  syphilis.^ 

These  results  of  Gi'assi  have  more  recently  been  confirmed  by  "\Yil- 
bouchewitch,^  who,  in  a  series  of  ten  observations,  also  determined  that 
the  i"ed  blood  glolndes  are  diminished  and  the  white  globules  increased  in 
number.  The  following  table  of  this  observer  shows  the  modifications  in 
the  number  of  globules  during  the  primary  stage  of  syphilis. 

'  HicouD,  Le9ons  sur  le  Chancre,  2d  ed.,  p.  184. 
2  Arch,  de  physiologic,  pp.  50!),  537,  1874. 


488 


STATE    OF    THE    BLOOD. 


Red. 

White. 

No.  of  red  to 
one  white. 

Healthy  mail'  .          .         .         .         .  -J 

4,200,000 
to  6,477,000 

6,900 
to  8,550 

603 

to  757 

Si/philltic  siihject : — 

1st  count       

4,170,000 

9,000 

421 

2(1       "       3  days  later 

5,510,000 

10,000 

437 

1st      " 

5,282,000 

13,900 

380 

2(1       "       4  days  later 

3,864,000 

11,550 

336 

1st      "          .         .         . 

4,338,060 

10,000 

433 

2d       "       3  days  later         .         , 

3,908,000 

12,800 

325 

1st      " 

5,040,000 

6,950 

72.') 

2d        "       3  days  later 

4,269,000 

5,600 

762 

1st      " 

4,392,800 

8,800 

565 

2d        "       4  days  later 

3,960,600 

7,000 

565 

1st      "          .         .         . 

4,314,800 

13,900 

332 

2d       "       3  days  later 

3,614,000 

10,800 

347 

1st      ". 

3,950,600 

7,900 

564 

2d       "       4  days  later 

3,600,300 

7,600 

473 

1st      " 

6,338,400 

6,950 

912 

2d       "       4  da^'s  later 

4,297.800 

7,000 

612 

1st      " 

4,886,400 

11,200 

436 

2d       "       6  days  later 

4,200,800 

13,600 

308 

1st      " • 

4,300,600 

8,000 

537 

2d       "       3  days  later 

3,600,400 

11,200 

321 

From  this  it  appears  tliat  the  average  diminution  in  the  number  of  red 
globules  as  found  in  the  second  count  was  638,870,  and  the  increase  in 
white  was  550 ;  the  proportion  of  white  globules  to  red  in  the  first  enume- 
ration was  1  to  530  and  in  the  second  ]  to  448. 


Syphilitic  Fever. 

The  fact  that  elevations  of  the  temperature  of  the  body  occur  during  the 
course  of  .syphilis  has  long  been  known.  Much  valuable  information  on  the 
subject  has  been  furnished  of  late  years  by  Fournier,  Courteaux,  Lance- 
reaux,  Bremer,  Jarnovsky,  and  especially  by  Dr.  T.  E.  Giintz,  of  Dresden. 

In  the  first  volume  of  the  Archives  of  Dermatology,  N.  Y.,  p.  345,  may  be 
found  the  results  of  observations  made  by  us  with  reference  to  this  subject 
in  sixty-two  cases.  Giintz  is  of  the  opinion  that  syphilitic  fever  occurs 
in  only  about  20  per  cent,  of  patients,  but  we  believe  that  careful  exami- 
nation will  discover  it  in  the  majority  of  cases.  It  may  be  transitory  or 
persistent ;  it  may  be  so  mild  as  to  escape  notice,  or  it  may  be  moderately 
intense.  It  presents  two  forms  ;  in  one  the  febrile  condition  is  continuous, 
in  the  other  it  shows  distinct  remissions. 

Let  us  first  consider  the  continuous  fever  which  accompanies  the  evolu- 
tion of  syphilis,  well-named  by  the  Germans  the  "  eruption-fever."  It 
seldom  occurs  before  the  tliirtieth  day  of  the  secondary  period  of  incuba- 
tion, that  is,  ten  days  prior  to  tlie  evolution  of  secondary  symptoms.  In  at 
least  half  the  cases  of  syphilis  there  is  no  febrile  reaction  until  within 
three  or  four  days  of  the  first  evidences  of  constitutional  infection.     In 


SYPHILITIC    FEVER.  489 

rare  cases  the  temperature  may  reach  103°  or  even  105°  within  twenty- 
four  or  forty-eight  hours.  Frequently  it  does  not  exceed  101°,  remaining 
at  that  point  until  the  eruption  appears,  when  it  again  rises  possihly  to 
105°.  It  then,  as  a  rule,  falls  gradually  or  abruptly  to  about  102°.  In 
almost  all  cases  there  is  a  difference  of  about  one  degree  between  the 
morning  and  evening  temperature.  In  other  cases  a  temperature  of  105° 
is  observed  ten  or  twelve  days  before  the  end  of  the  secondary  {)eriod  of 
incubation,  and  continues,  without  remission,  until  the  eruption  appears, 
when  it  falls  abruptly  to  102°,  where  it  may  remain  for  several  days.  In 
the  majority  of  our  cases  102°  has  been  about  the  average  temperature. 

Some  observers  consider  the  febrile  reaction  a  reliable  indication  of 
constitutional  infection,  but  in  some  cases  the  eruption  precedes  the  fever 
by  an  interval  of  a  week  or  ten  days. 

The  remarkable  effect  of  mercury  upon  the  temperature  has  been  noticed. 
Its  use  causes  a  reduction  nearly  or  quite  to  the  normal  standard  in  some 
cases  within  ten  days,  whereas  without  it  the  febrile  condition  may  persist 
for  several  months. 

Early  in  the  secondary  period  the  fever  is  prone  to  relapse,  possibly  at 
the  same  time  with  a  recurrence  of  general  or  special  syphilitic  symptoms. 
In  these  cases  the  temperature  rarely  goes  above  102°. 

When  phagedaina  attacks  the  initial  lesion  and  syphilitic  cachexia  ap- 
pears early,  the  fever  is  likely  to  be  excessive  and  prolonged.  In  weak 
and  sickly  persons  the  elevation  is  notably  greater  than  in  the  robust,  and 
in  women  it  is  higher  than  in  men.  We  fully  agree  with  Fournier  that 
syphilitic  fever  occurs  more  frequently  in  females  than  in  males.  The 
febrile  reaction  accompanving  an  erythematous  syphilide  is  often  as  ex- 
treme as  in  a  simple  eruptive  fever.  In  most  cases  of  papular  eruption 
the  fever  is  moderate.  In  cases  of  pustular  eruption  and  of  iritis  accom- 
])anying  general  secondary  symptoms,  it  is  more  marked.  In  general  the 
febrile  reactions  of  the  early  years  of  syphilis  are  more  intense  than  those 
occurring  later.  Indeed  lesions  of  much  gravity  may  occur  after  the  lapse 
of  years,  unaccompanied  by  fever.  On  the  other  hand  it  may  coexist  with 
the  various  nervous  and  visceral  affections  of  the  tertiary  stage. 

Syphilitic  fever  not  infrequently  presents  a  distinctly  remittent  type,  a 
peculiarity  which  may  be  notic<;d  in  the  early  period,  but  is  generally  not 
observed  until  late  in  the  course  of  syphilis.  We  have  seen  but  two  cases 
in  which  the  fever  began  in  a  remittent  form  ten  days  before  the  general 
outl>reak,  and  retained  its  character  for  nearly  three  weeks.  When  re- 
mittent fever  occurs  early,  it  usually  accompanies  the  develoi)ment  of  con- 
stitutional symptoms.  It  is  never  very  protracted.  The  exacerbations 
occur  as  a  rule  daily  and  towards  night,  beginning,  perhaps,  between  six 
and  eight  o'clock  with  a  general  cold  sensation,  soon  followed  by  fever. 
The  chilly  feeling  may  be  insignificant,  or  it  may  be  quite  marked,  and 
may  last  for  an  hour  or  more,  being  accompanied  by  a  feeling  of  lassitude 
and  soreness,  and  perhaps  by  headache,  more  or  less  severe.  Thirst  seems 
to  be  less  than  in  other  forms  of  fever.  The  sweating  stage  is  incomplete, 
there  frequently  being  only  slight  moisture  of  the  surface.     It  thus  differs 


490  AFFECTIONS    OF    THE    GANGLIA. 

from  malarial  fever  in  this  respect,  as  well  as  in  tlie  fact  that  the  stages 
are  neither  of  them  clearly  defined,  that  of  heat  being  most  marked.  The 
elevation  of  temperature  varies  from  102°  to  105°.  The  pulse  rate  is 
not  projjortionately  increased.  Relapses  are  quite  common,  even  after 
long  intervals.  The  gravity  of  the  fever  is  greatest  in  cachectic  subjects, 
in  whom  it  may  assume  a  typhoid  type. 

This  form  of  fever  occurs  most  frequently  in  the  secondary  period  during 
the  first  two  years  of  infection ;  yet  it  may  appear  in  the  tertiary  period, 
possibly  coexisting  with  lesions  peculiar  to  that  stage.  The  prognosis 
depends  wholly  on  that  of  the  associated  syphilitic  diathesis. 

Quinine  has  been  found  ineifective,  but  the  remittent  as  well  as  the 
continuous  form  is  strikingly  amenable  to  mercury.  The  curious  fact  is 
reported  by  Jullien  to  have  been  observed  by  Donienico  Copozzi,  that  in 
one  instance  the  salts  of  quinia  converted  a  quotidian  syphilitic  fever  into 
a  tertian  and  then  to  a  double  tertian,  when  it  relapsed  to  a  quotidian, 
which  finally  yielded  to  mercury. 

The  relation  of  the  febrile  reaction  to  tissue  metamorphosis  has  been 
made  the  subject  of  special  study  by  Vajda.  This  observer  found  marked 
increase  of  urea  in  a  patient  who  had  mercurial  stomatitis,  the  urea  dimin- 
ishing under  the  use  of  proper  doses  of  mercury.  Uric  acid  and  creatinine 
were  not  found  to  be  increased.  The  excretion  of  the  phosphates  was 
greater  in  exanthematous  than  in  bone  syphilis.  In  some  cases  a  distinct 
relation  was  observed  between  the  excretion  of  urea  and  phosphoric  acid ; 
and  sulphuric  acid  was  found  to  be  increased  in  the  papular  syphilides  in 
proportion  to  the  extent  of  the  eruption,  while  in  bone  lesions,  under 
mercurial  treatment,  it  at  first  increased  and  subsequently  diminished. 
Much  remains  to  be  done  in  the  investigation  of  this  subject. 

Affections  of  the  Ganglia. 

Engokgement  of  the  Superficial  Ganglia A  very  important 

symptom  of  the  early  stage  of  syphilis,  and  one  which  the  surgeon  should 
never  fail  to  look  for  in  cases  of  difficult  diagnosis,  is  engorgement  of  the 
lymphatic  ganglia  in  various  parts  of  the  body,  and  especially  those  situ- 
ated upon  the  lateral  and  posterior  portions  of  the  neck.  We  are  not  here 
speaking  of  the  induration  of  the  ganglia  in  anatomical  connection  with 
the  primary  sore — the  indurated  ganglia,  which  assume  their  cartilaginous 
hardness  about  the  same  time  as  the  base  of  the  chancre.  The  symptom 
referred  to  is  an  engorgement — not  induration — of  glands  at  a  distance 
from  the  point  where  the  virus  entered  the  system,  and  first  a[)pears  some 
six  or  eight  weeks  after  the  chancre  in  conjunction  with  other  early 
secondary  manifestations. 

This  symptom  is  present  in  a  large  majority  of  cases  at  this  stage  of  the 
disease.  Ricord  speaks  of  it  as  "perhaps  the  most  constant,  the  earliest, 
and  the  most  characteristic  symptom  of  constitutional  syphilis."^     Basse- 

'  Iconograpliie,  Remarks  on  the  case  figured  in  Plate  XLV. 


AFFECTIONS    OP    THE    GANGLIA.  491 

reau^  found  it  in  ninety  per  cent,  of  all  the  cases  of  syphilitic  erythema 
which  came  under  his  observation ;  and  in  most  of  the  exceptional  cases 
the  patients  had  taken  mercury  or  were  not  seen  for  some  time  after  the 
eruption  appeared.  It  is  an  early  syphilitic  symptom,  and  occurs,  if  at 
all,  within  a  year  after  contagion.  Ricord  states  that  it  is  rarely  seen  in 
persons  who  contract  syphilis  after  forty  years  of  age,  though  Bassereau 
met  with  one  case  in  a  man  aged  sixty-three,  and  another  in  one  aged 
seventy-four;  from  which  it  would  appear  that  this  rule  is  by  no  means 
invariable. 

The  glands  most  frequently  atfected  are  those  situated  along  the  upper 
two-thirds  of  the  posterior  border  of  the  sterno-cleido  mastoideus  muscle ; 
but  those  on  the  back  of  the  neck  beneath  the  occii)ut,  and  one  just  poste- 
rior to  the  ear  and  over  the  mastoid  process  may  also  be  involved.  All 
the  glands  in  the  regions  mentioned  are-  not,  however,  implicated  in  the 
same  person;  the  number  is  frequently  but  one  or  two,  and  rarely  exceeds 
six  or  eight.  In  a  state  of  health  these  bodies  can  with  difficulty  be  de- 
tected; but,  when  enlarged  by  syphilis,  they  may  attain  the  size  of  a  bean 
or  almond,  and  are  often  so  prominent  as  to  be  recognized  by  the  sight  as 
well  as  the  touch,  and  even  to  attract  the  notice  of  the  patient's  unpro- 
fessional associates.  As  a  general  rule,  their  number  and  size  correspond 
to  the  extent  and  severity  of  the  neighboring  eruptions  upon  the  scalp. 

Other  glands  besides  those  of  the  neck  may  be  engorged  in  the  same 
manner.  Sigmund  has  especially  insisted  upon  enlargement  of  a  lymphatic 
gland  situated  between  the  biceps  and  triceps  muscles  just  above  the  in- 
ternal condyle  of  the  liumerus,  where  we  frequently  observe  it,  although  we 
do  not  believe  it  to  be  as  constant  as  Sigmuntl's  remarks  would  lead  one 
to  suppose.  Bassereau  has  found  the  glands  of  the  axilla  affected,  but 
only  in  case  there  was  a  papular  or  pustular  eruption  in  the  neighborhood 
of  the  shoulder.  The  submaxillary  ganglia  are  also  not  unfrequently 
tumefied,  when  the  throat  is  the  seat  of  syphilitic  angina  or  when  the  mouth 
is  made  sore  by  the  use  of  mercury. 

This  engorgement  of  the  ganglia  almost  invariably  terminates  in  resolu- 
tion. In  one  case  only,  so  far  as  I  am  aware,  has  suppuration  been  known 
to  take  place.  This  occurred  in  a  patient,  aged  30,  of  a  scrofulous  habit, 
under  the  care  of  Bassereau,  in  whom  two  collections  of  matter  were  formed 
in  the  cellular  tissue  around  the  gland,  attended  by  severe  febrile  excite- 
ment and  re(piiring  puncture. 

Some  difference  of  opinion  has  been  entertained  as  to  the  question 
whether  this  engorgement  is  necessarily  dependent  upon  a  neighboring 
eruption  u[)on  the  scalp  or  integument.  Ricord  believes  that  it  is  not,  and 
states  in  support  of  his  opinion  that  it  often  occurs  before  the  slightest 
trace  of  an  eruption  is  visible ;  and  to  meet  the  objection  that  a  pustule  of 
ecthyma  might  be  concealed  in  the  hair  and  escape  notice,  this  surgeon 
has  repeatedly  shaved  the  head  and  proved  the  scalp  to  be  intact.  Ad- 
mitting, however,  that  the  engorgenumt  of  the  glands  precedes  the  erup- 
tion,  it   does   not  disprove   the   connection    between   the   two,   which   is 

'  Op.  cit.  p.  68. 


492  AFFECTIONS    OF    THE    GANGLIA. 

rendered  probable  by  the  correspondence  in  their  intensity;  and  swelling 
of  the  submaxillary  glands,  as  is  well  known,  is  often  anterior  to  an  erup- 
tion of  erysipelas  u})on  the  face.  Diday  is  confident  that  engorgement  of 
the  ganglia  does  not  exist  without  the  ])resence  of  some  affection  of  the 
neighboring  integument  or  mucous  membrane,  and  that  it  corresponds  in 
intensity  with  the  seventy  of  the  latter.  For  instance,  the  epi-trochlear 
gland  is  always  most  enlarged  upon  whichever  side  syphilitic  squamte 
u[)on  the  hand  are  most  marked. 

Dkep  Lymphatic  Ganglia Lancereaux  regards  changes  in  these 

ganglia  as  among  the  most  frequent  and  most  constant  of  the  effects  of 
tertiary  syphilis.  They  bear  the  same  relation  to  syphilis  of  the  viscera 
that  adenopathy  of  the  subcutaneous  lymphatic  glands  does  to  syphilis  of 
the  skin ;  in  other  words,  they  are  its  constant  accompaniment.  The 
affection  of  the  deep  lym[)hatic  glands  may,  however,  exist  without  any 
lesion  of  the  viscera,  just  as  the  post-cervical  and  epi-trochlear  glands  may 
be  enlarged  without  any  eruption  upon  the  scalp  or  arms. 

The  glands  most  frequently  affected  are  the  prevertebral,  lumbar,  iliac, 
and  femoral ;  the  mesenteric  glands  and  those  of  the  extremities  are  rarely 
involved.  The  changes  are  various.  Most  frequently  there  is  hyperplasia 
of  the  glandular  elements ;  the  gland  is  increased  in  length  rather  than  in 
brciidth,  is  friable,  of  soft  consistency,  of  a  reddish  or  yellowish-gray  color, 
its  surface  injected,  and  its  substance  cheesy.  In  other  cases  the  connec- 
tive tissue  of  the  gland  appears  to  be  the  cliief  seat  of  the  lesion,  and  this 
body  becomes  indurated.  Suppuration  is  never  present,  which  is  an  im- 
portant diagnostic  sign  between  this  and  the  affections  of  the  glands  in 
typhoid  fever,  and  in  tuberculosis. 

Two  forms  of  sy|)hilitic  adenitis  are  described  by  Cornil ;  the  secondary, 
and  the  other  of  the  tertiary  stage  of  syphilis.  In  the  former  the  micro- 
scope shows,  besides  the  lymi)h-corpuscles.  large  spheroidal  cells,  more 
numerous  in  the  cavernous  than  in  the  follicular  structure  of  the  gland. 
The  cells  contain  several  nuclei,  the  larger  of  which  inclose  nucleoli. 
There  is  also  slight  increase  of  the  connective  tissue,  so  that  there  exists 
cell-])roliferation  combined  with  a  moderate  degree  of  sclerosis.  In  terti- 
ary adenitis  the  swollen  ganglia  form  soft  whitish  masses  of  a  medullary 
appearance.  Round  and  granular  lymph-corpuscles,  and  large  multi- 
nucleated cells  crowd  the  cavernous  tissue  and  the  lymph-passages  of  the 
ganglia.  This  is  therefore  a  kind  of  catarrhal  inflammation.  Two  forms 
of  tertiary  adenitis  have  been  recognized  and  made  the  subject  of  a  thesis 
by  Gonnet,^  who  calls  them  sclerous  and  gummatous  adenitis.  He  says 
they  may  occur  together,  and  the  former  may  be  converted  into  the  latter. 

Thyroid  Booy — In  the  post-mortem  examination  of  old  syphilitic 
subjects,  this  gland  may  be  found  to  be  hypertrophied,  and  to  have  under- 
gone more  or  less  comj)lete  fatty  degeneration.  The  existence  of  gummy 
tumors  has  not  been  noted. 

'  L'ad^nopathie  syph.  tertiare,  Th^se  de  Par.,  1878. 


CACHEXIA,    CHLORO-AN.EMIA,    ASTHENIA.  493 


CHAPTER    VII. 

CACHEXIA,    CHLORO-AX.EMIA,    ASTHENIA. 

At  certain  periods  during  its  course,  syphilis  produces  an  adynamic 
condition  of  the  system,  called  "syphilitic  cachexia."  These  periods  are  at, 
or  just  before,  the  evolution  of  the  disease,  during  its  secondary  stage,  and 
towards  the  close  of  its  tertiary  stage. 

In  those  cases,  fortunately  rare,  in  which  phagp.dcenci  complicates  the 
initial  lesion,  there  may  be  observed,  soon  after  the  onset  of  this  process, 
loss  of  appetite  and  strength,  emaciation,  and  a  pale,  sallow  appearance. 
The  pulse  becomes  rapid,  weak,  and  small,  and  the  temperature  rises. 
The  patient  feels  dejected,  nervous,  and  apprehensive.  The  condition 
becomes  graver  in  proportion  to  the  extent  of  the  local  destructive  process, 
and  unless  this  be  checked,  complications,  consisting  of  numerous  functional 
disorders,  accompany  the  inauguration  of  the  secondary  stage.  Headache, 
neuralgic,  or  rheumatoid  pains,  with  severe  nocturnal  exacerbations,  may 
torment  the  unfortunate  sufferer,  whose  mind  is  equally  harassed  by  many 
forebodings,  as  for  instance,  in  the  case  of  phagedaina,  by  the  prospect  of 
losing  his  grenital  orgjans.  Decided  sranslionic  enlarpfement  usually  accom- 
panics  this  condition,  and  is  a  valuable  symptom,  since  the  secondary 
lesions  of  the  skin  and  mucous  membranes  may  be  so  trifling  as  to  elude 
search,  and  the  masked  character  of  the  initial  lesion  obscures  the  diag- 
nosis. We  have  often  noticed  the  disproportion  between  the  character  of 
the  primary  lesion  and  that  of  the  early  general  manifestations,  and  we 
have  seen  several  cases  in  which  the  very  considerable  extent  of  the  local 
process,  and  the  insignificance  of  the  secondary  symptoms  have  prevented 
any  suspicion  of  syphilis,  the  severity  of  the  systemic  disturbance  being 
attributed  to  the  phagediena.  The  )iecessity  of  thorough  and  repeated 
scrutiny  of  every  possible  seat  of  secondary  symptoms  in  all  cases  is  evident. 

In  some  cases,  secondary  and  tertiary  lesions  of  an  extremely  severe 
type,  may  coexist  with  the  primary  lesion,  and  the  patient  may  lapse  into 
a  typhoid  state,  or  serious  nervous  affections  may  be  developed,  and  even 
terminate  fatally.  Fortunately  such  a  result  is  rare,  but  it  is  not  uncommon 
to  see  a  phagedenic  chancre  accompanied  by  a  cachexia,  which  may  continue 
for  several  months,  and  from  which  recovery  is  tedious  and  attended  by 
repeated  relapses. 

The  cachexia  of  the  secondary  period  of  syphilis  may  begin  a  few 
months  after  the  onset  of  the  disease.  It  is  seen  chiefly  in  weakly  persons 
oftener  than  in  the  robust ;  and  again,  more  fre<iuently  in  those  who  have 
had  imperfect,  or  no  treatment  whatever ;  hence  we  have  reason  to  infer 
that  early  and  adequate  treatment  will  prevent  its  occurrence.     The  gene- 


494  CACHEXIA,    CHLORO-AN.^MIA,    ASTHENIA. 

ral  symptoms  of  cachexia,  already  given,  are  repeated  in  this  stage  of 
syphilis,  in  a  milder  form.  Frequently  nothing  can  be  found  to  account 
for  the  condition,  and  the  only  suspicious  feature  of  the  case  is  the  occur- 
rence of  headache  or  pain,  dae  to  a  low  grade  of  inflammation  in  bony  or 
fibrous  tissue,  and  which  are  more  severe  at  night. 

In  most  instances  there  is  no  reason  to  anticipate  an  unfavorable  result, 
but  in  others,  these  vague  symptoms  are  so  alarming  as  to  suggest  serious 
visceral  lesions.  We  have  sometimes  found  slight  enlargement  and  tender- 
ness of  the  liver  and  often  marked  splenic  hypertrophy.  The  urine,  in 
uncom[)licated  cases,  is  usually  of  very  low  specific  gravity  and  deficient 
in  mineral  ingredients. 

In  spite  of  the  serious  nature  of  the  case,  gradual  restoration  to  health 
may  be  expected  under  appropriate  treatment. 

The  cachexia  of  the  tertiary  stage  is  most  frequently  seen  in  severe  and 
protracted  cases  occurring  in  persons  of  weak  constitution,  or  in  those 
■who  have  failed  to  observe  the  laws  of  hygiene  or  who  have  not  been  sub- 
jected to  proper  treatment. 

The  condition  is  less  alarming  than  that  of  the  secondary  stage,  but  more 
chronic  and  rebellious.  Tertiary  lesions  have  probably  been  develojjcd 
early  and  severely,  and  very  likely  have  relapsed  with  increased  severity. 

iS'o  definite  order  of  symptoms  accompanies  the  cachexia  of  the  tertiary 
stage.  There  is  emaciation  and  debility  ;  the  patient  is  of  a  pale,  earthen 
hue,  which  differs  from  the  yellowish-white  of  the  cancerous  cachexia,  and 
resembles  the  tint  of  the  miasmatic  cachexia.  Remissions  may  occur 
during  which,  even  if  the  patioU's  appearance  does  not  improve,  his 
strength  is  increased,  and  his  general  condition  is  better. 

The  causes  of  tertiary  cachexia  are  various.  In  some  instances  it  is  due 
to  the  long  and  severe  course  of  the  disease ;  in  others  to  the  exhaustion 
fi'om  extensively  destructive  lesions,  and  in  others  still  to  visceral  lesions. 

The  prognosis  must  vary  in  individual  cases.  Unless  the  case  has  gone 
too  far,  treatment  may  induce  cure  or  decided  amelioration,  while  in  other 
instances  nothing  more  can  be  accomplished  than  temporary  retardation 
of  the  fatal  result.  Even  visceral  lesions,  if  not  too  extensive  or  too  chronic 
may  be  relieved. 

Fournier,  the  results  of  whose  studies  regarding  syphilis  in  women  are 
very  valuable,  considers  that  the  female  is  usually  more  seriously  affected 
than  the  male  sex.  He  thinks  that  syphilis  produces  in  the  foi'mer  two 
conditions,  one  "  chloro-amcmia,"  and  another  more  severe,  "asthenia." 

The  chloro-antemic  woman  has  a  pale  leaden  color,  slightly  tinged  with 
yellow,  is  emaciated,  weak,  and  subject  to  palpitations  on  slight  exertion. 
Frequently  an  anemic  bruit  may  he  heard  in  the  large  vessels.  The 
patient  complains  of  muscce  volitautes,  of  vertigo  and  of  excessive  nervous- 
ness. The  a[)[)etite  may  be  impaired  or  it  may  be  ravenous,  large  quanti- 
ties of  food  being  taken  and  not  assimilated.  Fournier  terms  this  "  ioz<- 
limie,"  or  a  temporary  exaggeration  of  the  appetite.  While  admitting  its 
occurrence  in  those  who  present  many  nervous  symptoms,  he  insists  on 
its  specific  origin.     It  is  probable  that  "  boulimie"  and  the  unnatural  thirst 


CACHEXIA,    CHLORO-ANaEMIA,    ASTHENIA.  495 

termed  "polydipsia,"  Avliich  ai-e  often  associated  together,  are  hysterical 
symptoms  resulting  from  the  depressing  influence  of  syphilis. 

The  condition  of  asthenia  is  regarded  by  Fournier  as  totally  distinct 
from  chloro-ana?mia,  since  those  women  who  are  the  subjects  of  it,  show 
no  evidence  of  anaemia  in  the  countenance.  They  complain  of  great  weak- 
ness and  prostration,  and  are  low  spirited  and  indisposed  to  any  kind  of 
exertion,  and  even  gentle  exercise  induces  fainting.  Fournier  says  that 
the  debility  is  greater  than  is  observed  in  cases  of  profuse  hemorrhage  or 
in  convalescence  from  adynamic  fevers.  The  pulse  is  weak,  respiration  is 
slow,  digestion  is  deranged,  and  nutrition  is  imperfect.  Nervous  depres- 
sion is  indicated  by  dulness  of  hearing  and  sight,  and  by  inability  to  sus- 
tain prolonged  mental  effort. 

This  condition  is  often  combined  with  chloro-aniiemia,  and,  like  the  latter, 
varies  greatly  in  severity,  and  is  amenable  to  proper  treatment. 

The  danger  in  each  of  these  conditions  is  from  the  diminished  resist- 
ance of  the  system,  which  lends  a  malignant  feature  to  any  intercurrent 
affection  that  may  attack  the  patient. 


496  INFLUENCE    OF    SYPHILIS    UPON    THE    CONSTITUTION, 


CHAPTER   YIII. 

INFLUENCE   OF    SYPHILIS   UPON   THE 
CONSTITUTION. 

The  division  of  syphilis  into  two  distinct  varieties,  mild  (faible)  and 
severe  (forte),  as  suggested  by  prominent  French  syphilographers,  is  too 
sharply  drawn  and  is  not  now  generally  accepted.  In  all  countries  where 
syphilis  has  existed  for  many  years,  its  course  is  much  less  severe  than  it 
was  originally,  and  the  disease  of  to  day  is  really  mild  in  comparison  with 
what  it  was  wlien  first  observed  in  Europe.  It  is  well  established  that 
syp-hilis  is  especially  malignant  when  appearing  for  the  first  time  in  a  com- 
munity. Numerous  instances  are  recorded  of  the  frightful  ravages  pro- 
duced by  it  under  such  circumstances.  The  initial  lesions  are  said  to  have 
been  phagedenic  and  to  have  been  followed  by  severe  secondary  symptoms, 
while  necroses  and  visceral  lesions  were  almost  invariable  and  precocious. 
This  malignancy  gradually  diminishes  in  successive  generations  until  a 
comparatively  mild  form  of  the  disease  is  established.  It  seems  that  a 
certain  protective  influence  is  secured  to  progeny  by  the  occurrence  of 
syphilis  in  their  ancestors,  which,  although  not  conferring  absolute  immunity 
decidedly  modifies  the  course  of  the  disease.  Thus  our  ideas  of  the  nature 
of  syphilis  are  free  from,  that  fear  with  which  our  forefathers  were  accus- 
tomed to  regard  it,  and  we  no  longer  look  upon  it  as  an  incurable  disease. 

Various  circumstances  have  contributed  to  this  change.  Undoubtedly 
the  progress  of  civilization  has  been  of  signal  influence  in  establishing  im- 
proved hygienic  and  sanitary  conditions.  Thus  the  standard  of  nutrition 
has  been  raised  and  the  ability  to  resist  disease  increased.  In  our  own 
country  the  people  of  the  poorer  classes  are  in  general  better  nourished 
and  better  cared  for  than  in  many  European  communities.  It  thus  happens 
that  among  us  scrofula,  rickets,  and  other  adynamic  conditions  are  much 
less  frequent  than  abroad. 

Another  potent  influence  in  lessening  the  severity  of  syphilis  is  found  in 
our  improved  knowledge  of  its  treatment.  Within  the  past  ten  years  great 
advances  have  been  made  in  the  therapeutics  of  this  disease.  Many  erroi's 
have  been  eliminated,  and  new  principles  have  been  established  on  a  more 
correct  basis. 

The  severity  of  syphilis  is  largely  modified  by  the  constitution  and  tem- 
perament of  the  patient.  As  a  rule,  in  persons  of  good  health  and  habits, 
its  course  is  mild  and,  provided  treatment  be  followed,  it  becomes  extinct 
in  a  few  years.  It  is  likely  to  be  more  severe  in  persons  of  light  com- 
plexion and  reddish  hair,  and  who  have  a  nervous  temperament,  than  in 
those  of  dark  complexion. 


INFLUENCE    OF    SYPHILIS    UPON    THE    CONSTITUTION.         497 

Syphilis  affects  persons  variously  at  different  ages.  The  hereditary 
disease  is  often  very  malignant,  but  acquired  syphilis  in  children  is  usually 
not  remarkably  severe.  About  the  age  of  puberty  the  lesions  of  syphilis 
are  apt  to  be  very  extensive,  and  the  consequent  impairment  of  nutrition 
very  great.  In  females,  its  course  is  generally  severe,  especially  at  puberty. 
After  maturity  the  constitution  is  less  affected,  and  fortunately  the  disease 
is  most  often  contracted  at  this  period,  when  the  vital  processes  are  most 
active  and  the  powers  of  resistance  most  energetic.  Wlien  contracted  in 
okl  age,  syphilis  is  frequently  a  very  serious  disease.  The  secondary  stage 
is  then  remarkable  for  the  number,  severity,  and  malignancy  of  its  lesions. 
The  tertiary  lesions  are  prone  to  appear  early,  and  visceral  complications 
and  nervous  affections  are  frequent. 

It  is  obviously  difficult  to  determine  positively  whether  the  severity  of 
syi)hilis  depends  or  not  on  the  intensity  of  the  infecting  poison.     It  would 
certainly  seem  very  natural  that  virus  from  a  recent  and  active  syphilis  is 
likely  to  produce  an  intense  form  of  the  disease,  and  vice  versa,  but  we 
have  no  facts  to  confirm  the  opinion.     On  the  other  hand,  we  often  see 
two  patients,  wlio  derive  their  disease  from  the  same  source,  presenting 
one  a  mild  and  the  other  a  severe  form  of  syphilis.     We   are   therefore 
warranted  in  believing  that  the  constitution  of  the  patient  has  much  more 
influence  in  shaping  the  character  of  his  disease  than  the  quality  of  the 
virus  absorbed.     With  rare  exceptions  the  severity  of  the  disease  is  in 
proportion  to  the  general  health  of  the  patient.     Persons  of  lymphatic 
temperament  or  of  scrofulous  liabit  are  particularly  liable  to  active  and 
prolonged  attacks  of  syphilis.     They  exhibit  an  especial  tendency  to  ulcer- 
ation and  destruction  of  tissue.     The  debility  and  impaired  nutrition  left 
by  the  continued  fevers,  diphtheria,  and  other  exhausting  diseases,  have  a 
very  unfavorable  influence  on  the  course  of  syphilis.     Alcoholism  seems 
to  increase  the  gravity  of  the  cachexia  and  the  destructive  tendencies  of  the 
lesions.    It  is  in  alcoliolic  cases  that  we  meet  with  many  of  the  instances  of 
malignant  syphilis  called  by  the  French  ^^  (jalloping^^  (^sypliih's  gallopante). 
As  we  have  already  observed,  the  course  of  syphilis  is  in  a  great  mea- 
sure governed  by  the  treatment.     If  the  use  of  medicine  be  begun  early, 
and  carefully  continued,  even  in  those  whose  constitution  is  not  very  good, 
the  disease  may  be  cured,  if  we  may  be  allowed  to  assume  a  person  cured 
who  for  years  presents  no  manifestations  of  the  disease,  and  wlio  propa- 
gates healthy  children.     The  majority  of  authorities  now  hold  tlie  opinion 
that  syphilis  is  a  curable  disease.     In  this  we  concur,  and  we  believe  it 
right  to  promise  any  patient,  whose  health  is  not  seriously  undermined  by 
some  other  disease,  that  he  may  expect  complete  recovery  by  undergoing 
treatment  for  tlie  first  two  years  of  his  disease,  and  by  paying  ordinary 
attention  to  hygiene.     The  importance  of  the  early  use  of  mercury  after 
tlie  development  of  secondary  lesions  cannot  be  overestimated.     A  far 
better  effect  is  secured  than  if  its  use  is  postponed.     In  our  experience 
tei-tiary  lesions  luive  been  almost  unknown   where  tlie  disease  has  been 
gradually  and  carefully  treated  from  the  outset.     In  the  vast  majority  of 
82 


498         INFLUENCE    OF    SYFIIILIS    UPON    THE    CONSTITUTION. 

cases  of  tertiary  sypliilis  under  our  care  for  many  years,  the  histories 
showed  neglect  or  inadecjuacy  of  treatment,  and,  in  many  of  them,  the 
iodide  of  potassium  had  been  relied  upon  during  the  first  year  when 
mercury  should  always  be  given. 

Influence  of  Syphilis  upon  Diseases  in  General. 

Syphilis  may  exert  an  influence  upon  various  intercurrent  diseases, 
first  on  those  of  an  acute  course,  second  on  chronic  diseases,  and  third  on 
those  of  traumatic  origin. 

Influence   on  Acute    Diseases Very  little    is    known,  beyond  a  few 

isolated  facts,  as  to  its  influence  on  acute  diseases.  Bamberger  and  Fron- 
miiller  speak  of  the  transformation  of  variola  pustules  into  syphilitic  ulcers 
and  tubercles  in  infected  subjects,  and  Lancereaux  thinks  that  in  an  epi- 
demic of  smallpox  observed  by  him  there  were  more  cases  of  the  hemor- 
rhagic variety  in  syphilitic  patients  than  in  those  not  infected  with 
syphilis.  In  an  epidemic  of  scarlet  fever,  Woakes  observed  a  fatal  result 
particularly  in  infants  afflicted  with  hereditary  syphilis.  Acute  rheuma- 
tism, occurring  in  the  early  months  of  the  sy[)hilitic  diathesis,  has  been 
observed  to  run  an  exceptionally  severe  course  and  to  be  prone  to  relapse. 
Pneumonia,  bronchitis,  and  pleurisy,  during  the  course  of  syphilis,  are 
liable  to  be  more  or  less  modified.  Pneumonia,  complicating  a  severe 
cachexia  in  the  early  months  of  syphilis,  is  a  most  serious  accident,  and 
often  leads  to  a  fatal  result.  In  later  stages,  though  less  malignant,  these 
diseases  are  often  rendered  much  more  severe  and  protracted.  Little  can 
be  said  of  the  influence  of  syphilis  upon  the  specific  fevers.  It  is  safe  to 
assume  that  the  severity  of  the  fever  will  be  proportionate  to  the  gravity 
of  the  syphilitic  cachexia. 

Influence  on  Chronic  Diseases The  difficulty  of  obtaining  facts  on  this 

subject  leaves  our  knowledge  with  regard  to  it  sadly  deficient.  The  opinion 
has  long  been  held  that  syphilis  has  an  unfavorable  influence  on  scrofula 
and  tuberculosis,  and  that  indeed  it  may  produce  them.  It  is  now  known 
that  the  so-called  scrofulous  lesions  have  a  distinct  morbid  origin,  and  are 
pathologically  different  from  those  of  syphilis.  Like  any  depressing  dis- 
ease, syphilis  may  increase  the  severity  of  scrofula  and  of  tuberculosis. 
Tubercles  are  not  a  syphilitic  product,  and  their  occurrence  in  a  syphilitic 
subject  is  a  mere  coincidence.  It  is  not  worth  while  to  consider  the  dif- 
ferent speculations  on  this  subject.  In  the  section  on  affections  of  the  lungs 
we  shall  refer  to  the  various  changes  which  are  etiologically  related  to 
syphilis.  As  regards  the  relation  between  syphilis  in  parents  and  tuber- 
culosis in  children,  the  observations  of  Thoresen  are  worthy  of  attention. 
This  author  followed  the  family  history  of  three  hundred  and  eighteen 
cases,  and  was  unable  to  trace  phthisis  in  the  child  to  syphilis  in  the 
parents,  Avhile  in  every  case  of  a  tuberculous  child  there  was  evidence  of 
tuberculosis  in  the  parents. 

In  nine  tuberculous  individuals  who  became  syphilitic,  the  course  of 
the  disease  was  very  disastrous,  and  in  twelve  syphilitic    persons    who 


INFLUENCE    OF    SYPHILIS    UPON    DISEASES    IN    GENERAL.      499 

belonged  to  a  tuberculous  race,  though  the  syphilitic  lesions  were  severe, 
no  evidences  of  tuberculosis  or  of  chest  affections  ever  existed. 

Among  other  important  chronic  diseases  gout  and  rheumatism  are  no 
doubt  largely  affected  by  syphilis,  particularly  in  its  late  period  of  cachexia. 
It  may  be  safely  predicted,  that,  when  a  person  subject  to  chronic  inflam- 
mation becomes  infected  with  syphilis,  he  Avill  suffer  in  after  years  from 
a  combination  of  the  two  diseases,  unless  treatment  be  most  thoroughly 
followed.  It  is  useless  to  speculate  concerning  the  reason  of  this  fact,  but 
as  to  its  being  a  fact  we  have  positive  evidence.  Such  a  patient  is  espe- 
cially liable  to  recurrent  attacks  of  muscular  pains,  more  severe  at  night. 
They  come  on  at  varying  intervals,  often  seemingly  influenced  by  damp 
and  cold  weather,  and  are  seldom  accompanied  by  febrile  movement. 
Chronic  inflammation  of  the  fibrous  tissues  of  the  joints  is  especially  common 
and  persistently  recurrent.  Periostitis,  particularly  of  the  long  bones,  is 
common  in  these  cases,  and  the  development  of  a  marked  form  of  cachexia 
is  especially  noticeable.  This  cachexia  is  attended  by  all  the  symptoms  of 
profound  systemic  depression  ;  it  may  become  rapidly  fatal,  or  health  may 
be  established  after  a  tedious  convalescence,  recurrences,  however,  being 
not  imcommon.  Some  of  these  cases  are  seriously  complicated  by  visceral 
affections,  especially  of  the  liver. 

The  relation  between  syphilis  and  gout,  although  supported  by  so  relia- 
ble an  observer  as  Sir  James  Paget,  is  not  generally  accepted.  A  gouty 
subject,  in  whom  syphilis,  after  running  a  chronic  course,  settles  into  a 
state  of  cachexia,  presents  a  condition  characterized  by  inflammation  of 
fibrous  tissues  and  of  joint  structures,  recurring  at  intervals,  or,  in  other 
words,  a  modified  form  of  gout.  Moreover,  cerebral  symptoms,  not  often 
congestive  but  still  quite  formidable,  are  frequently  present,  while  disturb- 
ances of  respiration,  of  the  heart,  and  of  the  stomach,  referrible  to  gout, 
may  be  manifested.  The  etiology  of  cases  of  this  kind  should  be  carefully 
studied,  the  subject  being  one  of  the  most  important  in  syphilography. 

The  absence  of  etiological  relation  between  lupus  and  syphilis  is  now 
fully  recognized.  Tiiere  is  not  the  least  evidence  to  support  the  opinion 
that  lupus  of  tlie  child  is  due  to  syphilis  in  the  parents.  Lupus  is  a  dis- 
tinct form  of  skin  disease,  whose  histological  features  somewhat  resemble 
those  of  syphilis,  but  it  is  in  no  way  related  to  the  latter  disease,  and  it 
decidedly  resists  anti-syphilitic  remedies. 

In  patients  suffering  from  scorbutus  and  the  hemorrhagic  diathesis, 
syphilis  has  been  known  to  be  very  severe.  Its  lesions  are  likely  to  be 
complicated  by  hemorrhage  and  ulceration,  and  a  severe  cachexia  is  not 
infreriuent.  P^ffusion  into  serous  cavities  often  occurs,  and  joint  affections 
are  peculiarly  distressing. 

In  cases  of  Bright's  disease  syphilis  usually  takes  a  very  rapid  course, 
and  has  an  especially  adynamic  influence. 

Patients  with  an  hereditary  or  an  acfpiircd  predisposition  to  nervous  dis- 
eases are,  after  infection,  especially  liable  to  syphilitic  aflfecti(jns  of  the 
brain  and  nerves. 


500       influence  of  syphilis  upon  the  constitution. 

The  Influence  of  Syphilis  upon  Traumatism. 

The  importance  of  this  subject  is  very  great  in  respect  to  surgical  ope- 
rations. To  the  hibors  of  Verneuil  we  owe  the  clearest  statement  of 
this  influence,  which  is  given  in  the  following  conclusions,  taken  from  the 
thesis  of  J.  L.  Petit,  a  student  of  the  accomplished  French  surgeon. 

1.  In  cases  of  severe  syphilis  or  of  ordinary  syphilis,  which  has  been 
untreated  or  indifferently  treated,  traumatic  lesions  may  present  a  peculiar 
aspect  or  take  an  abnormal  course. 

2.  These  characters  may  be  observed  either  immediately,  or  a  few  days 
or  weeks  or  even  several  months  after  the  receipt  of  the  injury. 

3.  Sometimes  the  wound  becomes  a  true  syphilide ;  again  it  ulcerates 
without  assuming  specific  features ;  or,  finally,  it  does  not  cicatrize,  or 
does  so  very  slowly. 

4.  When  syphilitic  lesions  exist  at  the  time  of  its  infliction,  the  wound 
assumes  an  appearance  similar  to  that  of  syphilitic  ulcerations  in  pi'ocess 
of  evolution. 

;").  Traumatism  supervening  in  syphilitics  of  whom  the  diathesis  is 
latent  (the  period  of  infection  being  somewhat  remote)  may  induce  syphi- 
litic manifestations  in  the  wounded  region  (local  manifestations),  or  at  a 
point  more  or  less  distant  (manifestations  at  a  distant  point),  or  upon  a 
surface  more  or  less  general  (general  manifestations). 

(j.  These  manifestations  or  lesions  are  induced  as  readily  in  the  tertiary 
as  in  the  secondary  period. 

7.  Syphilis  may  localize  itself  at  the  seat  of  a  traumatic  lesion  in  a 
region  previously  free  from  any  of  its  manifestations. 

y.  The  syphilitic  affection  may  then  be  either  an  ulceration  destroying 
the  cicatrix,  or  a  tumor  which  follows  the  usual  course  of  a  gumma. 

9.  Traumatic  lesions  of  syphilis  generally  have  the  characters  distinc- 
tive of  its  natural  manifestations,  and  are  cured  by  similar  treatment. 

10.  In  certain  cases,  syphilis  seems  to  be  the  determining  cause  of  the 
complications  of  wounds. 

11.  These  complications  are  also  capable  of  inducing  syphilitic  mani- 
festations. 

12.  At  first  the  specific  nature  of  traumatic  afl'ections  and  the  compli- 
cations of  wounds  may  be  dilficult  of  recognition,  sufllicient  information 
being  almost  always  unobtainable.  When  a  wound  assumes  an  ulcerating 
character,  and  shows  no  reparative  tendency,  no  other  morbid  cause  being 
discovered,  it  is  well  to  bear  in  mind  this  possibility,  and  to  employ  remedies 
appropriate  to  syphilis. 

13.  Previous  to  tiie  performance  of  an  operation,  which  is  not  urgent, 
in  particular  autoplasty  (and  indeed  any  operation  attended  by  solution  of 
continuity),  upon  a  patient  who  recently  presented  syphilitic  symptoms,  it 
would  be  prudent  to  prescribe  mercury  or  the  iodide  of  potassium. 

1 4.  In  case  of  failure  of  this  operation,  the   patient  should  be  again 


INFLUENCE    OF    SYPHILIS    UPON    TRAUMATISM.  501 

placed  under  treatment,  and  tlie  operation  should  not  be  repeated  until  at 
least  six  months  after  the  disappearance  of  sypliilitic  symptoms. 

Instances  are  on  record  of  fractures  occurring  during  the  active  stage  of 
syphilis,  which  have  failed  to  unite  until  treatment  had  been  followed  for 
a  lonf  time.  Under  similar  conditions  the  callus  of  fractures  has  been 
known  to  be  destroyed,  leaving  the  fragments  ununited. 


502  PROGNOSIS    OF    SYPHILIS. 


CHAPTER    IX. 
PROGNOSIS   OF    SYPHILIS. 

Tmo  opinion  very  generally  prevails,  that  syphilis  is  a  disease  Avhich,  if 
left  to  itself,  will  always  go  on  from  bad  to  worse,  attack  in  its  progress 
the  deeper  und  more  important  organs,  and  probably  terminate  in  death. 
The  correctness  of  this  opinion,  at  least  so  far  as  concerns  its  invariability, 
may  well  be  called  in  question,  since  syphilitic  {)atients  are  rarely  allowed 
to  go  without  treatment,  and  consecjuently  little  opportunity  is  atforded 
for  observing  the  natural  progress  of  the  disease ;  and  we  cannot  logically 
infer,  because  certain  cases,  in  spite  of  remedies,  pursue  a  disastrous  course, 
that  the  same  would  have  been  true  of  others,  which  have  terminated 
favorably,  if  the  treatment  had  been  less  thorough,  or  had  been  altogether 
omitted.  It  would  be  more  reasonable,  though  less  flattering  to  ourselves, 
to  conclude  that,  as  art  has  been  comparatively  impotent  in  the  former,  it 
can  claim  for  itself  but  a  portion  of  the  credit  in  the  latter;  in  fact,  that 
very  nuicli  depends  upon  the  severity  of  the  disease,  which  varies  greatly 
in  ditierent  cases. 

Tliere  is  reason  to  believe  that,  in  many  instances,  under  favorable  cir- 
cumstances, this  disease  tends  to  self-limitation.  I  have  been  struck  with 
the  fact  that  some  patients,  who  either  through  neglect  or  ignorance  fail 
to  pursue  any  continued  course  of  treatment,  still  live  in  com|)arative  com- 
fort, and,  alter  several  attacks  of  general  symptoms,  extended  through  a 
number  of  years,  are  finally  free  from  further  annoyance;  the  disease 
probably  remaining  dormant  in  the  system,  but  ceasing  to  betray  itself  by 
any  external  manifestation,  I  have  seen,  as  pi-obably  nearly  every  surg'XJn 
has  who  has  had  nuich  to  do  with  venereal,  ])atients  now  perfectly  well, 
but  bearing  evident  marks  of  former  syphilis,  and  who  are  yet  totally 
ignorant  that  they  ever  had  the  disease,  and  who  certainly  have  never 
been  treated  for  it.  Two  cases,  out  of  a  number  that  might  be  related, 
will  suffice  to  illustrate  this  point. 

A  young  man,  aged  21,  was  brought  to  my  office  in  consultation  for  so- 
called  morbid  sensibility  of  the  retina.  On  examining  his  eyes,  I  find  pos- 
terior synechia,  indicating  an  attack  of  iritis  at  some  previous  time.  After 
considerable  trouble  in  unravelling  his  case,  I  ascertain  the  following  facts: 
At  the  age  of  1(>  lie  contracted  an  ulcer  upon  the  penis  from  impure  inter- 
course; three  months  after  he  had  sore  throat,  scabs  in  the  hair,  alopecia, 
and  an  eruption  upon  the  skin ;  six  months  after  he  had  an  inflamed  eye, 
attended  with  considerable  intolerance  of  light,  and  pain.  He  was  at  the 
time  young  and  ignorant  of  any  such  disease  as  syphilis  ;  was  told  by  his 
attending  physician  that  he  had  caught  cold  in  his  eye,  and  had  never 


PROGNOSIS    OF    SYPHILIS.  503 

suspected  the  nature  of  his  complaint.  The  well-informed  physician  Avho 
brought  him  to  my  office  told  me  that  he  had  been  under  his  observation 
for  the  last  two  years,  and  had  never  presented  the  slightest  symptom  of 
syphilis,  and  the  most  careful  examination  failed  to  discover  any  activity 
of  the  poison  at  the  time. 

Again,  a  young  lady,  aged  18,  accompanied  by  her  mother,  came  to  my 
office  to  be  treated  for  interstitial  keratitis.  Believing,  as  I  do,  in  the 
general  truth  of  Dr.  Hutchinson's  views  as  to  the  specific  character  of  this 
affection,  I  at  once  examined  the  teeth  and  found  that  conformation  of  the 
central  upper  incisors  which  is  so  characteristic  of  congenital  syphilis. 
After  closely  questioning  the  mother,  there  could  be  no  doubt  that  she, 
shortly  after  her  marriage,  was  infected  with  syphilis  by  her  husband,  but 
she  had  never  had  the  slightest  suspicion  of  it  nor  had  she  ever  been  sub- 
jected to  specific  treatment,  although  she  is  now  in  the  enjoyment  of  perfect 
health. 

Again,  evidence  of  a  tendency  to  self-limitation  is  found  in  many  cases 
in  which  treatment  is  faithfully  pursued,  and  in  which  the  disease,  under 
the  best  management  on  the  part  of  tlie  surgeon,  and  the  utmost  obedience 
of  orders  by  the  patient,  repeatedly  recurs  for  a  time,  and  yet  ultimately 
disappears,  without  our  being  able  to  attribute  this  happy  termination  wholly 
to  the  accumulated  effect  or  prolonged  use  of  remedies,  which  have  failed  to 
afford  permanent  relief  in  the  earlier  attacks.  I  have  so  often  found  this 
to  be  the  case,  that  I  do  not  hesitate  to  assure  patients,  when  discouraged 
by  the  reappearance  of  symptoms  which  they  supposed  Avere  cured,  that 
the  tendency  to  return  will  probably  cease  after  a  time,  and  leave  them  in 
the  enjoyment  of  a  fair  state  of  health;  although  never,  after  treatment 
however  prolonged,  do  I  promise  certain  imniunity  for  the  future.  I  can 
recall  to  mind  quite  a  number  of  patients  whom  I  treated  for  syphilis  ten 
or  fifteen  years  ago,  and  whose  disease  repeatedly  returned,  and  was  appa- 
rently uncontrollable  by  medicine  for  a  period  of  from  one  to  three  years, 
but  who  have  since  been  exem[)t  from  further  trouble,  and  many  of  whom 
have  married,  and  become  the  fathers  of  healthy  children ;  and  I  cannot 
honestly  ascribe  their  present  immunity  wlioUy  to  the  remedies  employed, 
but  in  a  measure  to  the  fact  that  the  activity  of  the  disease  has  been 
exhausted.' 

Tliis  tendency  to  self-limitation — or,  as  it  may  be  called,  spontaneous 
quiescence — of  syphilis,  has  been  carefully  studied  by  several  authors, 
notably  by  Diday  and  Zeissl.  Diday's  mode  of  practice  has  afforded  liim 
a  most  excellent  opportunity  for  deciding  this  point,  since,  in  the  great 
majority  of  syi)liilitic  cases,  he  withholds  all  treatment,  unless  compelled 
to  its  resort  by  tlie  urgency  of  the  symjjtoms.  As  the  results  of  his  ex- 
perience since  adopting  this  course,  Diday  remarks,  in  the  first  place,  that 
he  has  been  struck  with  the  regular  evolution  and  succession  of  syphi- 
litic phenomena,  and  afterwards  goes  on   to  say,  that  in  many  cases,  the 

'  "That  all  the  constitutional  forms  of  sypliilitic  aifoctions,  if  left  to  the  un- 
aided i»o\vcrs  of  nature,  liave  a  constant  tcndenc^y  to  wear  themselves  out,  I  am 
fully  convinced." — Eoan,  Sj/j)hilUic  Diseases,  p.  245. 


504  PROGNOSIS    OF    SYTHILIS. 

disease  never,  passes  beyond  the  secondary  stage ;  that,  after  several  suc- 
cessive attacks — as,  for  instance,  of  mucous  patches,  exantheinatous  or  pap- 
uhu-  eruptions,  etc. — the  symptoms  diminish  in  intensity  ;  the  virus  appears 
to  be  elimiuated  by  the  natural  jiowers  of  the  system  ;  tlie  tendency  to 
fresh  manifestation  disappears,  and  a  permanent  and  spontaneous  cure  is 
obtained.  In  other  cases,  on  the  contrary,  he  has  found  the  disease  be- 
come more  serious  and  more  deeply  rooted  by  time  ;  hence,  he  admits  two 
classes  of  cases,  in  one  of  which  syphilis  naturally  decreases,  and  in  the 
other  increases  in  intensity  ;  in  the  former,  he  resorts  to  hygienic  measures 
alone  ;  in  the  latter,  he  employs  specifics,  but  not  to  the  neglect  of  hy- 
giene.^ 

Out  of  forty-three  cases,  treated  by  the  non-mercurial  j)lan,  in  twenty- 
six  the  general  symptoms  never  assumed  a  serious  cliaracter  and  consisted 
merely  of  sy|)liilitic  fever,  acne  ca])itis,  roseola,  and  mucous  patches.  These 
lesions  n^appeared  on  several  occasions,  but  always  with  decreasing  severity  ; 
the  disease  never  passed  into  the  tertiary  stage  ;  and  finally  the  general 
health  M'as  completely  re-established.  In  eighteen  of  these  cases,  sufficient 
time  had  elapsed  to  render  the  permanence  of  the  cure  all  but  certain  ;  thus, 
the  period  between  the  last  syphilitic  manifestation  and  the  date  when  the 
patients  were  last  seen  in  perfect  health  was  in — 


3 

cases 

3 

4 

3 

1 

1 

1 

1 

1 

3* 
4 

years, 

^ 
5 

6 

8 

9 

.6 

On  the  other  hand,  in  seventeen  of  the  forty-three  cases  treated  with- 
out mercury,  the  symptoms  assumed  a  more  serious  aspect,  threatening 
impairment  of  various  organs  and  permanent  injury  to  the  constitutioi ; 
some  of  them  passed  into  the  tertiary  stage  ;  and  the  safety  of  the  patients 
demanded  tiie  administration  of  mercury,  which  was  accordingly  given. 
The  following  table  exhibits  the  difference  in  these  two  classes  of  cases  in 
respect  to  the  number  of  the  successive  appearances  or  outbreaks  of  gene- 
ral symptoms  : — 


Number  of  outbreaks. 

In 

THE 

MILD 

SERIES. 

In 

THE  SEVERE  6 

1 

. 

3 

cases. 

2 

. 

14 

(( 

. 

. 

.     3  cases. 

3 

8 

(( 

, 

.     4     " 

4 

. 

1 

(( 

. 

.     3     " 

5 

or 

6    . 

. 

. 

. 

.     7    " 

Besides  being  more  numerous,  the  outbreaks  of  general  manifestations, 
as  a  general  rule,  occurred  at  shorter  intervals  in  the  severe  than  in  the 
mild  class  of  cases. 

•  Nouvelles  doctrines  sur  la  syi^hilis,  p.  302  et  seq. 


PROGNOSIS    OF    SYPHILIS.  505 

According  to  Diday,  the  following  are  the  most  valuable  indications  to 
show  that  an  attack  of  syphilis  in  a  given  case  will  be  mild  :  a  long  incu- 
bation and  a  superficial  cliaracter  of  the  initial  lesion,  or  chancre  ;  simple 
roseola  without  papules  as  tlie  first  manifestation  upon  the  skin  ;  a  gradual 
diminution  in  the  size  of  the  engorged  ganglia  ;  infrequent  outbreaks  of 
general  manifestations,  separated  by  comparatively  long  intervals,  and  de- 
creasing in  severity. 

On  the  other  hand,  a  severe  attack  is  indicated — by  a  short  incubation 
and  deep  ulceration  of  the  primary  lesion  ;  by  the  eru[)tion  upon  the  scalp 
assuming  a  decidedly  pustular  character ;  by  ulceration  of  mucous  patches 
in  positions  where,  in  mild  cases,  they  are  almost  always  superficial,  as 
upon  the  sides  of  the  tongue,  on  the  scrotum,  margin  of  the  anus,  or  vulva  ; 
a  papular,  vesicular,  pustulous,  or  squamous  eruption  as  the  first  syphilide  ; 
persistency,  or  having  once  subsided,  tardy  reappearance  of  the  glandular 
engorgement  ;  frequency  and  increasing  severity  of  the  successive  out- 
breaks of  general  manifestations. 

The  severity  of  the  attack  does  not  appear  to  be  in  direct  ratio  with 
that  of  the  syphilitic  fever  which  commonly  precedes  or  accompanies  the 
earliest  outbreak  of  general  symptoms,  the  fever  frequently  being  most 
severe  in  those  cases  which  prove  the  mildest ;  nor,  so  far  as  we  know, 
can  any  indication  be  drawn  from  the  length  of  the  period  of  incubation 
of  general  manifestations.  Hereditary  origin  has  an  aggravating  influence 
upon  syphilis,  both  in  the  infant  and  in  any  person  to  whom  the  latter 
may  communicate  it ;  on  the  contrary,  syphilis  contracted  from  a  second- 
ary lesion  (of  acquired,  not  hereditary  syphilis)  has  been  supposed  to  be 
of  a  mild  type.^  The  above  indications,  however,  should  be  received 
with  much  caution,  as  tliey  are  founded  upon  a  small  number  of  statistics, 
and  require  further  investigation.  In  my  own  experience,  they  have  re- 
peatedly been  falsified,  although  I  am  not  prepared  to  deny  their  value  in 
general. 

Zeissl's  views  with  regard  to  the  self-limitation  of  syphilis  and  its  ex- 
pectant treatment  (given  in  the  Wien.  Med.  Wchnschr.,  1879,  Nos.  1, 
2,  3,  4)  are  essentially  the  same  as  Diday's,  yet  he  freely  confesses  that 
he  rarely  carries  them  out  in  practice,  either  in  hospitals  or  in  private — 
not  in  the  former,  because  economy  reciuires  that  patients  should  be  re- 
lieved and  discharged  as  soon  as  possible ;  nor  in  the  latter,  because 
patients  are  unwilling  to  submit  to  a  prolonged  duration  of  their  symp- 
toms and  demand  speedy  relief. 

While  fully  concurring  with  these  views  of  Diday  and  Zeissl  as  to  the  self- 
limitation  of  syphilis  in  many  cases,  I  am  convinced  that  their  tendency, 
unless  great  caution  be  used,  is  mischievous  in  underestimating  tlie  value 
and  importance  of  treatment.  It  is  true  that  many  cases  of  this  disease  will 
do  well  under  a  merely  expectant  treatment,  but  no  one  can  tell,  a  priori, 
■which  cases  will  do  well  and  wliich  will  do  bjidly.  There  is  a  dark  side 
of  the  picture  which  must  not  be  forgotten  while  looking  at  the  liglit  one, 

'  Diday,  Ilistoiro  iiatun^llo  do  hv  syphilis. 


506  TROGNOSIS    OF    SYPHILIS. 

and  the  former  includes  the  many  evils — the  physical  deformity,  public 
infamy  and  disgrace,  and  the  ignominious  death — to  which  syphilis,  when 
neglected,  exposes  its  victim.  Prolonged  treatment,  adapted  to  the  re- 
quirements of  each  case,  is  the  surest  safeguard  for  every  one  who  has 
been  so  unfortunate  as  to  contract  this  disease. 


IRRITABILITY    OF    SKIN    AND    MUCOUS    MEMBRANES.  507 


CHAPTER   X. 

IRRITABILITY  OF  THE  SKIN  AND  MUCOUS  MEM- 
BRANES. CHANGES  IN  THE  SENSIBILITY  OF 
THE    SKIN. 

In  the  early  stages  of  syphilis  the  skin  and  mucous  membranes  are 
peculiai'ly  susceptible  to  inflammation ;  the  tendency  becomes  less  marked 
as  the  diathesis  grows  older.  It  is  greater  in  some  subjects  than  in  others, 
those  having  a  delicate  white  skin  possessing  it  more  decidedly.  The  in- 
tegument of  those  who  have  had  pustular  and  ulcerating  syphilides  is  more 
liable  to  become  inflamed  from  a  slight  cause  than  of  those  who  have  had 
erythematous  and  ])a])ular  rashes.  This  altered  condition  of  the  skin  and 
mucous  membranes  is  seen  in  its  most  simple  form  in  the  extreme  inflam- 
mation attending  slight  cuts  and  abrasions,  and  in  a  greater  degree  in  the 
excessive  ulceration  and  suppuration  during  the  course  of  certain  non-spe- 
cific skin  diseases,  such  as  acne,  eczema,  impetigo,  and  pemphigus.  Not 
infrequently  herpetic  vesicles,  in  recently  infected  syphilitic  patients, 
become  very  much  inflamed  and  present  the  features  of  chancroids  with 
their  peculiar  destructive  tendency.  (See  p.  30.)  Doubtless  owing  to 
this  condition  of  the  tissues,  blennorrhagia  sometimes  becomes  especially 
vii'ulent.  Examples  of  auto-inoculation  with  blennorrhagic  pus  are  not 
uncommon.  Brought  in  contact  with  an  abrasion  or  herpetic  vesicles 
about  the  genitals,  or  becoming  lodged  in  the  follicles,  it  causes  violent 
reaction  and  ulcers  resembling  chancroids. 

Our  knowledge  of  the  influence  of  various  irritants  upon  the  integument 
has  been  much  extended  by  numerous  experiments  in  inoculation  with  pus 
from  venereal  lesions,  and  by  the  observation  of  cases  of  sy[)hilis  treated 
by  syphilization.  The  results  have  confirmed  what  is  sometimes  seen 
clinically.  It  is  proved  that  the  integument  of  some  persons  is  more  sus- 
ceptible than  tliat  of  others,  and  that  certain  kinds  of  pus  are  more  active 
than  others.  The  secretions  from  chancroids  and  from  ulcerating  syj)hi- 
litic  lesions  are  much  more  active  than  those  from  wounds  or  from  simple 
skin  lesions.  The  experiments  of  Wigglesworth,  already  referred  to,  and 
of  Morgan,  who  produced,  with  vulvo-vaginal  pus,  ulcers  which  resembled, 
and  which  were  essentially  chancroids,  illustrate  this  abnormal  irritability  of 
the  skin.  Repeated  inoculation  is  known  to  lessen  this  tendency  to  ulcer- 
ation, until  finally  scarcely  any  efiect  is  produced.  Moreover,  dilution  of 
the  pus  diminishes  its  action. 

Irritation  of  the  skin  of  syphilitics  may  also  cause  infiltration  witli  or 
withoirt  ulceration.     A  splinter  of  wood,  imbedded  in  the  skin,  has  been 


508  IRRITABILITY    OF    SKIN    AND    MUCOUS    MEMBRANES. 

known  lo  give  rise  to  a  tubercle,  having  all  the  appearance  and  character 
of  a  spc'ciHc  lesion.  In  many  cases  of  artificially  j)ro(luced  ulceration  in- 
filtration coexists,  and  remains  long  after  cessation  of  the  destructive  pro- 
cess. Wounds,  bruises,  and  ulcers  are  liable  to  become  complicated  by 
this  nodular  infiltration.  This  tendency  to  infiltration  ceases  with  the 
extinction  of  the  syphilitic  diathesis,  whereas  the  tendency  to  ulceration 
persists  long  after  the  completion  of  cure.  This  fact  is  exemplified  in  the 
ulcerations  and  fissures  occiu-ring  in  the  mouths  of  smokers,  when  syphilitic 
manifestations  have  long  since  disappeared. 

This  peculiar  condition  of  the  skin  is  wortliy  of  special  consideration  in 
connection  with  the  serpiginous  syphilides.  These  creeping  ulcers  un- 
doubtedly originate  in  true  syphilitic  lesions,  but  the  decided  absence  of 
characti^ristic  features  in  tlieir  future  course  warrants  the  sus[)icion  that 
they  become  simple  chronic  ulcers  developed  upon  a  favorable  soil. 

The  fact  tluit  during  syphilis  slight  abrasions  and  herpetic  vesicles 
may  give  rise  to  ulcers  resembling  chancroids  is  of  great  practical  import- 
ance, and  its  thorough  recognition  will  enable  the  physician  to  avoid  doing 
injustice  to  innocent  persons. 

■    Changes  in  the  Sensibility  of  the  Skin. 

As  first  noticed  by  M.  A.  Fournier,  syphilis  very  commonly  gives  rise 
to  various  disorders  of  the  general  sensibility,  esj)ecially  in  women.  The 
most  frequent  of  these  is  a  loss  of  the  perception  of  pain,  or  analgesia,  with 
which  is  sometimes  combined  the  absence  of  the  sense  of  touch  and  of 
temperature.  In  such  cases,  for  instance,  a  pin  may  be  thrust  deeply 
into  the  flesh  without  the  patient's  suftering  any  pain,  or  she  may  be  also 
insensilde  to  the  touch  of  the  fingers,  or  cannot  distinguish  between  hot 
and  cold  substances. 

Syphilitic  analgesia  varies  in  degree  in  different  cases,  and  also  in  the 
extent  of  the  surface  affected.  In  some  instances  it  extends  from  head  to 
foot,  in  others  it  is  confined  to  particular  regions,  when  the  extremities  of 
the  limbs,  as  the  hands,  the  lower  half  of  the  forearms,  the  feet  and  ankles, 
are  almost  invariably  involved.  The  back  of  the  hand,  over  the  dorsal 
surface  of  the  metacarpus,  is  a  favorite  site,  where  it  is  likely  to  be  found, 
if  anywhere.  This  disorder  occurs  during  the  early  secondary  period,  and 
most  commonly  lasts  for  several  months.  Fournier  says  that  he  has 
observed  over  a  hundred  cases  within  two  years. 

Cases  of  this  affection  have  frequently  come  under  our  observation  both  in 
the  male  and  the  female  sex.  It  would  ])robably  be  found  oftener  if  looked 
for,  but  its  presence  is  of  no  special  value  either  in  the  way  of  prognosis 
or  treatment,  and  is  lience  for  the  most  })art  neglected. 


SYPHILIDES.  509 


CHAPTER   XI. 
S  YPHTLIDES. 

Lesions  of  the  skin  may  appear  at  any  period  in  the  course  of  syphilis, 
being  among  its  earliest  symptoms  and  not  infrequently  among  its  latest. 

Syphilitic  eruptions  are  caused  by  two  distinct  morbid  processes,  hyper- 
jemia  and  cell  infiltration,  each  of  which  is  extremely  chronic  in  its  nature. 
The  hyperremic  or  erythematous  syphilides  present  several  varieties,  and 
ai"e  peculiar  to  the  early  stages  of  syphilis,  being  very  rarely  seen  later 
than  two  years  after  infection.  While  hypera;mia  is  the  essential  morbid 
process,  Ave  not  infrequently  find  associated  with  it  a  certain  degree  of 
cell  increase,  sometimes  so  slight  as  to  be  inappreciable  to  the  naked  eye, 
and  again  so  marked  as  to  form  well-defined  patches  or  nodules.  The 
infiltrating  cells  of  the  syphilitic  dermal  lesions  are  round,  granular,  nucle- 
ated bodies,  averaging  -^jj^q^  of  an  inch  in  diameter,  similar  to  the  white 
blood-corpuscles  in  general  appearance,  and  analogous  to  the  cells  of  the 
initial  lesion  and  of  the  later  gummatous  tumors  of  syphilis.  The  surpris- 
ingly numerous  and  varied  appearances,  resulting  from  these  two  simple 
processes,  are  modified  and  complicated  by  various  subsequent  changes. 

As  a  general  rule  the  cell-infiltration  is  in  proportion  to  the  age  of  the 
syphilis.  Thus,  in  the  secondary  period  the  superficial  layers  of  the  skin 
are  involved,  and  papules  are  developed  ;  while  at  a  later  period,  the  infil- 
tration being  deeper  and  more  extensive,  tubercles  are  formed.  In  the 
former  the  changes  take  place  chiefly  in  the  pajnllary  and  Malpighian 
layers  ;  in  the  latter  the  derma  and  the  subcutaneous  tissue  are  involved. 
A  tubercle,  therefore,  is  simply  a  papule  of  large  size.  Evidently  there 
can  be  no  distinct  line  of  division  between  the  two  lesions,  and  we  i're- 
quently  meet  with  intermediate  grades  of  infiltration,  to  which  we  may 
apply  the  term  papulo-tiiberch.  Tubercles  may,  however,  a))pear  early 
in  the  course  of  syphilis,  but  are  usually  not  seen  until  after  the  evolution 
of  a  general  superficial  eruption.  A  syphilitic  pustule  may  be  looked  upon 
as  a  pus-producing  papule,  the  secretion  of  i)us  generally  being  secondary 
to  the  formation  of  the  papule.  In  some  instances,  however,  the  forma- 
tion of  pus  seems  to  precede  or  to  be  coincident  with  the  cell  infiltration. 

The  occurrence  of  a  vesicular  syphilide  is  rare,  and  has  indeed  been 
denied  by  some  authors.  It  is  true  that  vesicles,  similar  to  those  of  herpes 
and  eczema,  are  not  developed,  but  it  is  not  uncommon  to  find  minute 
collections  of  serum  beneath  the  epidermis  at  the  apices  of  papules,  espe- 
cially those  small  conical  papules  wliicli  have  a  more  acute  ciiaracter. 

The  existence  of  a  true  bullous  syphilide  in  the  acquired  disease  liaa 
also  been  doubted,  but  we  are  convinced  that  it  is  occasionally  developed  at 


510  SYnilLIDES. 

a  late  period  in  cachectic  subjects.     The  degree  of  cell  infiltration  at  the 
base  of  bulliv  is  usually  much  less  than  in  any  other  syphilitic  eruption. 

Thus  we  find  in  syi)hilis  lesions  of  the  integument  which  correspond  to 
those  of  non-specific  origin  :  erythemata,  papules,  pustules,  vesicles,  bullae, 
and  tubercles,  but  the  syphilitic  eruptions  present  certain  peculiar  features 
whose  recognition  is  important. 

In  addition  to  the  above-mentioned  lesions  are  the  syphilitic  gmnmata 
or  gummatous  tumors.  These  result  from  cell  infiltration  in  the  sub- 
dermal  tissue,  either  limited  to  this  region  or  involving  secondarily  the 
entire  thickness  of  the  skin,  which  may  be  destroyed,  thus  forming  gum- 
matous ulcers.. 

A  syphilitic  eruption  may  be  composed  exclusively  of  one  or  another  of 
these  lesions,  or  several  may  be  simultaneously  developed. 

Much  confusion  has  followed  the  application  to  syphilitic  skin  lesions  of 
the  classification  of  non-specific  eruptions  instituted  by  Willan,  who  placed 
lichen  among  the  papular,  im[)etigo  among  the  pustular,  eczema  among 
the  vesicular,  and  psoriasis  among  the  scaly  affections.  Such  a  nomen- 
clature in  syphilis  is  far  from  being  as  useful  as  might  be  expected.  For 
instance,  a  papular  syphilide,  in  its  early  stage,  would  be  called  "  lichen  ;" 
but  suppose  it  to  be  cajjped  with  pus,  as  frequently  happens,  and  the  name 
"  im[)etigo"  must  be  substituted,  or  we  must  designate  it  by  the  term 
"  pustulating  syphilitic  lichen."  Should  the  lesion  lose  its  pustular  fea- 
ture, and,  becoming  chronic,  assume  a  scaly  character,  no  term  now  in 
use  could  express  the  exact  condition,  and  we  should  be  compelled  to  add 
the  term  psoriasis. 

Another  objectionable  feature  in  the  nomenclature  of  syphilitic  dermal 
lesions,  is  the  use  of  the  word  "  lupus"  in  describing  certain  tubercular 
syphilitic  lesions  whose  features  and  course  resemble  those  of  the  non- 
specific affections. 

We  have,  therefore,  thought  best  to  apply  the  qualifying  adjectives, 
"  erythematous,"  "  papular,"  "  pustular,"  etc.,  to  the  generic  term  "•  syphi- 
lide," using  the  words  "  ulcerating,"  "  serpiginous,"  etc.,  in  addition,  as 
the  peculiar  features  of  an  eruption,  in  exceptional  cases,  may  require. 
We  thus  avoid  the  erroneous  inference  that  many  of  the  chief  varieties  of 
simple  skin  affections  are  caused  by  syphilis. 

Although  we  may  use  the  word  "  scaling"  in  describing  certain  syphi- 
lides,  it  must  be  remembered  that  desquamation  does  not  constitute  the 
lesion,  but  that  the  latter  consists  of  infiltrations  into  tlie  skin,  in  the  form 
of  papular  or  tubercular  eruptions,  exfoliation  of  the  epidermis  being  second- 
ary. In  some  cases  the  dermal  irritation  is  so  excessive  that  desquama- 
tion continues  long  after  the  original  lesion  has  faded.  It  must  then  be 
considered  merely  a  sequel  of  the  specific  process. 

Besides  the  classification  of  syphilides  in  accordance  with  their  element- 
ary lesions,  we  have  one  based  on  tlie  recognized  fact  that  each  symptom 
has  a  favorite  period  of  development.  A  strict  chronological  order  is  not 
followed,  for  a  tubercular  rash  may  be  met  with  at  an  early  date,  or  a 
papular  eruption  may  be  developed  very  late  in  the  course  of  syphilis. 


SYPHILIDES.  511 

Some  French  authors  call  the  early  eruptions  precocious  syphilides  (syphi- 
lides  precoces),  and  limit  them  to  the  first  eight  months  of  the  disease ; 
those  of  later  appearance  they  term  intermediary  (<'n<erwerfm«Ves),  whicli 
may  appear  as  late  as  the  second  year  ;  while  the  very  latest  are  called 
tardy  {tardives)^  which  may  appear  at  any  time  before  the  tenth  or  the 
twentieth  year. 

A  division  which  is  simpler  and  more  practical,  and  which  we  shall  em- 
ploy, is  that  which  places  erythematous,  papular,  pustular,  and  vesicular 
syphilides  among  secondary  lesions,  and  tubercular,  bullous,  ulcerative, 
and  gummatous  among  tertiary  lesions.  Certain  peculiarities  are  pre- 
sented by  tliese  two  classes  of  lesions. 

Tlie  early  lesions  of  the  secondary  stage  are  distributed  symmetrically 
and  generally  over  the  body,  involving  the  superficial  layers  of  the  skin  ; 
the  later  lesions  of  this  stage,  although  extensively  and  symmetrically 
spread,  are  less  copious,  and  show  a  tendency  to  localization,  and,  more- 
over, invade  deeper  portions  of  the  skin.  The  lesions  of  the  tertiary  stage 
are  always  profound,  and  are  less  pi'ofusely  distributed,  but  they  involve 
more  extensive  portions  of  particular  regions  for  which  they  seem  to  have 
a  predilection,  and  they  are  frequently  unsymmetrical.  The  course  of  the 
tertiary  lesions  is  decidedly  more  prolonged  and  indolent  than  that  of  the 
secondary. 

Much  difficulty  is  experienced  in  the  study  of  specific  skin  affections  in 
consequence  of  numerous  modifications  whicli  they  are  prone  to  undergo. 
Familiarity  with  the  features  of  the  simple  eruptions  is  essential  to  an 
accurate  knowledge  of  syphilitic  eruptions.  Let  us  now  consider  some  of 
the  characteristics  by  which  the  latter  may  be  recognized. 

Their  coxirse^  as  compared  with  that  of  simple  eruptions,  is  marked  by 
chronicity  and  absence  of  inflammatory  features.  They  may  be  accom- 
panied by  a  moderate  degree  of  systemic  reaction.  In  some  erythematous 
and  papular  syphilides  of  the  early  period  of  syphilis,  the  intensity  of  this 
reaction  and  the  active  character  of  the  eruption  may  render  the  diagnosis 
from  one  of  the  simple  exanthems  very  difficult.  The  actual  nature  of  the 
eruption  is  demonstrated  by  its  quickly  assuming  a  subacute  course.  With 
the  progress  of  the  syphilis  the  tendency  of  tlie  eruptions  to  present  a 
chronic,  apyretic  character  is  more  marked.  Some  local  exciting  cause 
may  usually  be  found  for  the  hyperuimia  and  inflammation  sometimes 
attending  tubercular,  ulcerative,  and  gummatous  syphilides. 

Absence  of  Itching  and  Pain Owing  to  their  indolent  nature  syphilitic 

eruditions  do  not,  as  a  rule,  cause  any  irritation  of  the  skin. 

Itching  may  be  present  in  connection  with  an  early  eruption,  whose 
evolution  is  particularly  acute.  It  is  never  so  intense  as  in  a  simple  erup- 
tion, and  is  much  more  ephemeral.  It  is  perhaps  more  troublesome  with 
an  eruption  occurring  on  the  scalp  than  elsewhere,  and,  when  complicating 
an  early  rash,  it  is  generally  limited  to  the  extremities,  the  upper  more 
often  than  the  lower. 

Too  much  reliance  must  not  be  placed  on  the  statement  of  a  patient  that 
an  eruption  itches.     We  must  remember  that  the  irritation  may  be  caused 


512  SYPttlLIDES. 

by  pediculi,  or  by  the  wearing  of  flannel,  and  that  some  persons  have  an 
excessively  irritable  skin. 

Pain  is  even  rarer  than  itching  in  syphilitic  dermal  lesions.  A  few  in- 
stances have  been  recorded  of  its  occurring  in  connection  with  a  tubercu- 
lar or  a  gummatous  syphilide. 

Puhjiiwrphism. — The  simultaneous  occurrence  of  several  varieties  of 
lesions  in  tlie  same  eruption  is  an  important  and  common  feature  of  syphi- 
lis. It  is  due  to  tliree  causes  :  the  chronic  course  of  syphilides,  their  re- 
lapsing tendency,  and  the  changes  occurring  in  the  lesions.  A  similar 
feature  may  be  observed  in  some  of  the  simple  eruptions,  as  eczema,  acne, 
and  scabies,  but  in  their  case  the  diversity  evidently  consists  of  modifica- 
tions of  the  original  lesion,  while  in  specific  eruptions  it  is  in  part  due  to 
the  development  of  new  tbrms  of  eruption  before  the  disappearance  of  pre- 
ceding ones.  Polymorphism  is  most  frequently  observed  early  in  the 
secondary  stage,  since  eruptions  are  then  more  numerous  ;  yet  it  may  exist 
even  with  the  late  tubercular  eruptions. 

Color  and  Pigmentation It  is  important  to  distinguish  the  color  of  the 

syphilides  from  the  pigmentation  which  frequently  follows  them. 

Their  usual  tint  is  pinkish-red,  being  much  more  subdued  than  that  of 
simple  eruptions.  Even  in  exceptional  cases  of  acute  invasion,  in  which 
the  color  may  be  unusually  bright,  it  is  less  intense  than  in  the  simple 
exanthemata.  The  hue  soon  fades  to  a  brownish,  which,  after  involution 
of  the  eruption,  changes  to  a  copper-colored,  yellowish-brown  maculation. 
Pressure  dissipates  the  color  during  the  early  stages  of  an  eruption,  but 
finally  the  pigmentation,  which  has  been  compared  to  "  the  lean  of  ham," 
to  the  color  of  copper,  and  to  a  combination  of  yellow  and  brown„  becomes 
permanent. 

These  pigmentary  changes  are  not  peculiar  to  syphilis,  being  equally 
well  marked  in  lichen  planus,  and  in  cases  of  protracted  dermatitis. 
They  are  probably  due  to  deposit  of  coloring  matter  of  the  blood  in  the 
affected  spots. 

In  persons  whose  circulation  is  feeble  the  color  of  the  pigmentation  may 
be  light  yellow,  and  in  cases  where  the  hyperannia  is  slight  and  of  short 
duration,  no  pigmentation  at  all  may  be  induced. 

It  is  claimed  by  some  authors  that  syphilis  may  produce  a  primary  pig- 
mentation, inde[)endently  of  any  preceding  pathological  process.  This 
condition  is  to  be  described  in  the  section  entitled  "  Pigmentary  syphilide." 

Tendency  to  Assume  a  Circular  Form The  early  eruptions  are  gene- 
rally distributed  over  the  surface  without  definite  order,  except  in  rare 
instances  in  particular  regions,  where  they  may  be  arranged  in  a  circular 
manner.  This  peculiarity  is  more  commonly  seen  in  the  case  of  small 
papular  rashes  and  in  the  erythematous  syphilide.  The  latter  often  relapses 
in  the  shape  of  distinctly  marked  rings,  differing  from  the  papular  syphi- 
lide, in  which  the  bases  of  the  papules  generally  merge  together  and  form 
simply  wavy  lines,  or  segments  of  circles,  or  perhaps  complete  circles.  In 
certain  large  papules,  and  in  some  papulo-tubercles,  involution  begins  at 
their  centres,  leaving  the  periphery  in  a  ringed  form.     A  similar  process 


SYPHILIDES.  513 

may  be  observed  in  psoriasis,  but  in  the  latter  extension  of  the  patch  may 
take  phice,  Avhich  is  usually  not  the  case  in  syphilis.  Ulcers  of  the  later 
stages  of  syphilis  may  likewise  exhibit  this  tendency.  Many  other,  though 
less  constant,  features  of  syphilitic  eruptions  will  be  considered  when  de- 
scribing individual  lesions. 

Influence  of  Mercury — By  many  mercury  is  considered  so  infallibly 
curative  of  syphilitic  eruptions  that  it  is  termed  the  "touch-stone"  in  their 
diagnosis.  Its  influence  is  certainly  wonderful  in  most  cases,  especially 
in  early  lesions  and  in  those  of  an  infiltrative  character;  but  certain  ulcer- 
ative and  chronic  forms,  particularly  tliose  attended  by  much  scaliness, 
are  often  quite  rebellious. 

In  general,  mercury  is  very  efficient  in  uncomplicated  cases,  but  in 
those  complicated  by  other  morbid  changes,  and  especially  in  those  which 
have  had  a  long  existence,  its  effect  is  much  less  pronounced. 

The  Influence  of  Intercurrent  Diseases  on  the  Course  of  Syphilides. 

The  course  of  syphilitic  eruptions  is  not  infrequently  interrupted  or  even 
permanently  arrested  by  some  acute  disease.  Numerous  instances  have 
been  reported  of  the  disappearance  of  an  eruption  at  the  outset  of  an  in- 
flammatory affection  of  the  lungs,  of  acute  articular  rheumatism,  of  various 
adynamic  fevers,  and  of  acute  cerebral  disease.  Jullien  mentions  the 
remarkable  case  of  a  young  man  who  was  vainly  treated  by  Diday  for 
lingual  mucous  patches  and  a  scaling  palmar  syphilide,  who  was  finally 
cured  during  a  general  eruption  of  furuncles. 

Variola  and  varioloid  have  been  known  to  have  a  similar  effect.  It  was 
once  claimed  that  syphilis  could  be  cured  by  vaccination,  but  careful  trial 
of  this  means  has  proved  its  uselessness. 

Our  knowledge  of  the  influence  of  erysipelas  on  the  course  of  syphilitic 
eruptions  is  derived  chiefly  from  the  French.^  Not  only  superficial  lesions, 
such  as  papules,  mucous  patches,  and  condylomata,  but  deep  and  diffiise 
tubercles  and  even  active  ulcerations  are  affected ;  not  only  lesions  within 
the  actual  range  of  the  erysipelatous  process,  but  even  those  at  a  distance 
are  influenced  by  it  in  some  obscure  way,  even  after  the  failure  of  well- 
directed  treatment.  When,  however,  the  syphilitic  diathesis  has  a  malig- 
nant character,  erysipelas  is  likely  to  be  a  fatal  complication. 

That  traumatic  as  well  as  idiopathic  erysipelas  may  have  a  curative 
effect  was  proved  in  a  case  reported  by  Mauriac,  in  which  well-marked 
syphilitic  lesions  were  dissipated  by  an  attack  of  the  disease  which  followed 
their  excessive  cauterization.  The  practical  value  of  this  fact  is  limited 
by  our  inability  to  excite  and  control  an  erysipelatous  inflammation. 

Intercurrent  diseases  have  no  influence  upon  the  syphilitic  diathesis, 
and  therefore  no  power  to  prevent  relapses. 

'  The  most  complftte  brochure  on  this  subject  is  that  of  the  celebrated  syphilo- 
grapher,  Mauriac  (Etude  clinique  sur  I'inttuence  curative  de  I'^rysipele  dans  la 
syphilis)  ;  and  more  recently  an  important  case  lias  been  reported  by  Deahna 
(Vrtljschr.  f.  Dermat.,  B.  iii,  1876,  p.  57). 
33 


514  SYPHILIDES. 

Unusual  Modes  of  Ei^olution. — The  appearance  of  a  general  eruption 
is  looked  upon  us  the  indication  of  constitutional  infection,  but  the  first 
eruption  may  be  limited,  and  a  general  rash  may  not  be  developed  for 
several  weeks.  In  some  cases  only  two  or  three  dermal  lesions  can  be 
found  at  the  usual  date  of  invasion.  Should  the  eruption  be  erythematous, 
the  spots  soon  become  coppery,  and  remain  in  a  chronic  condition;  if 
papular,  the  papules  are  sluggish,  and  usually  leave  a  i)igmented  spot. 
In  connection  with  these  scanty  lesions,  the  patient  may  suffer  from 
syphilitic  pains  in  the  head,  in  the  bones,  etc.,  and  perliaps  may  have 
erythema  of  the  fauces  and  high  temperature.  Within  two  to  six  weeks 
the  usual  general  eruption  follows. 

The  Localization  of  the  Syphilides — Syphilitic  eruptions  are  often 
found  in  regions  where  simple  skin  lesions  are  seldom  or  never  developed. 

vSecondary  eruptions  appear  on  the  scalp  and  especially  at  its  margin 
on  the  forehead,  at  the  angles  of  the  mouth,  on  the  alte  of  the  nose,  about 
the  anus  and  upon  the  genitals,  near  the  umbilicus,  in  the  inguinal  fold, 
between  the  toes,  and  upon  the  palms  and  soles.  The  supra-  and  infra- 
clavicular and  sternal  regions,  where  simple  and  parasitic  eruptions  are 
often  found;  are  rarely  the  seat  of  specific  exanthems,  and  on  the  dorsum 
of  the  hands  the  latter  are  not  often  seen.  Regions  rich  in  sebaceous  and 
hair  follicles  are,  as  a  rule,  less  frequently  invaded  by  simple  than  by  . 
specific  eruptions.  The  annular  forms  of  simple  erythema  may  occur  on 
any  part  of  the  body,  while  these  forms  of  the  erythematous  and  the 
papular  syphilides  are  more  likely  to  be  limited  to  the  neighborhood  of 
joints,  the  anterior  and  inner  surfaces  of  the  extremities,  and  the  gluteal 
regions. 

The  papular  syphilides  are  prone  to  be  developed  on  the  palms  and 
soles. 

Later  eruptions  are  generally  seated  upon  the  nose,  the  lips,  and  the 
scalp  ;  they  are  found  upon  the  scapular,  sternal,  and  gluteal  regions,  and 
more  often  on  the  legs,  near  the  joints,  than  on  the  thighs. 

Oharacters  of  the  Scales  and  Crusts  of  the  Syphilides The  scales  of 

specific  eruptions  are  thinner,  less  numerous,  and  less  glistening  than 
those  of  simple  eruptions,  and  they  are  very  rarely  imbricated.  They 
may  consist  of  epidermis  only,  when  they  have  a  dull  white  color, 
or  they  may  be  formed  chiefly  of  serum,  when  they  are  yellowish  or 
brownish.  The  scales  are  never  removed  in  large  patches,  as  in  psoriasis, 
since  the  inflammation  is  of  such  a  low  grade  that  exfoliation  is  slow  and 
scanty. 

The  crusts  of  syphilitic  pustules  and  ulcers  are  also  peculiar.  Those 
of  small  pustules  soon  dry,  and  are  seated  upon  an  indurated  base ;  those 
of  impetigo  and  eczema  are  placed  in  a  sliglit  depression  of  the  inflamed 
skin.  Tlic  crusts  of  larger  pustules  are  dark  brown  or  greenish-black, 
differing  from  those  of  ecthyma  and  scabies,  which  are  yellowish-brown. 


SYPIIILIDES.  515 

If  elevated,  the  sypliilitic  crust  is  seated  upon  a  deep  ulcer  with  brownish- 
red,  infiltrated  base  and  margins  ;  in  a  simple  eruption  the  ulcer  is  more 
superficial,  its  base  is  inflamed,  and  it  has  reddish,  violaceous  borders. 

The  ci'usts  of  rupia  have  no  analogue  in  dermatology.  They  are  of  a 
brownish-black  color,  are  conical  and  distinctly  laminated,  and  they  rest 
upon  a  surface  which  is  bathed  in  viscid  pus,  or  as  Zeissl  puts  it,  "  they 
swim  upon  and  are  kept  afloat  by  pus."  Their  shape  and  structure  are 
due  in  a  measure  to  their  slow  formation. 

The  crusts  of  late  syphilitic  ulcers  have  a  brownish-black  color  and  a 
rough  uneven  surface,  and  resemble  a  dirty  oyster  shell ;  the  crusts  of 
lupus  are  of  a  bluish-brown  mixed  with  yellow. 

Peculiarities    of  Ulcers    and    Cicatrices Syphilitic   ulcers    may    be 

round,  oval,  kidney-shaped,  or  of  the  form  of  a  horseshoe.  The  ulcers 
of  lupus  frequently  assume  similar  forms,  but  the  lesions  of  syphilis  are 
generally  more  numerous,  more  extensively  distributed  and  more  poly- 
morphous than  those  of  lupus.  The  character  of  the  crusts,  the  rapid 
progress  and  regular  margins  of  the  ulcer,  and  its  proximity  to  a  joint, 
the  general  history  of  the  case,  and  its  amenability  to  treatment,  distin- 
guish a  syphilitic  lesion.  The  margins  of  a  lupoid  ulcer  are  everted, 
softer  and  more  violaceous,  and  are  frequently  studded  with  reddish- 
blue  tubercles,  while  the  surrounding  tissues  are  much  swollen.  The 
cicatrices  of  syphilitic  ulcers,  especially  where  they  have  been  numer- 
ous, are  often  diagnostic.  They  are  distinctly  rounded  or  oval,  quite 
smooth  and  seldom  traversed  by  fibrous  bands  except  at  the  joints;  they 
are  frequently  perforated  with  minute  holes,  the  sites  of  former  follicles, 
when  they  are  more  or  less  depressed,  and  when  mature,  are  quite  pliable. 
Their  brownish-red  color  slowly  fades  from  the  centre  to  the  periphery, 
until  there  remains  a  white  shining  surface,  surrounded  by  a  narrow  areola 
of  brown  pigment.  A  lupoid  scar,  on  the  contrary,  is  generally  irregular 
in  outline ;  its  surface,  which  is  not  always  depressed,  but  may  be  on  a 
level  with  the  general  surface  or  even  elevated  by  the  subjacent  thickening, 
is  very  uneven  and  is  crossed  by  numerous  fibrous  bands;  it  has  not  a 
shining  appearance,  and  its  areola  is  bluish-red.  Finally,  false  keloid  is 
more  frequent  upon  lupoid  than  uj)on  sy[)liilitic  cicatrices. 

The  cicatrices  ^Yhich  sometimes  follow  papular  syphilides  are  small, 
more  or  less  aggregated,  and  at  first  pigmented.  They  are  recognized  by 
the  situation  and  grouping  of  the  scars,  the  coexistence  of  other  lesions  or 
their  sequelae,  and  by  the  history  of  the  case. 

The  Odor  of  Certain  Syphilitic  Lesions Some  observers  claim  that 

syphilis  always  gives  rise  to  a  distinctive  odor.  There  is  no  doubt  that 
tiie  discharges  from  certain  lesions  possess  an  offensive  and  somewhat 
peculiar  smell.  Mucous  tubercles,  when  seated  upon  the  genitals  or  in 
folds  of  integument,  yield  a  secretion,  often  combined  with  that  of  seba- 
ceous and  sweat  follicles,  which  has  a  sickening,  penetrating  odor  certainly 


516  SYPIIILIDES, 

never  perceived  in  other  lesions.  The  odor  in  some  cases  of  extensive 
gummatous  and  tubercuhu*  ulcerations,  where  the  secretion  is  a.bundant 
and  tlie  jjatient  uncleanly,  is  heavy  and  nauseating. 

General  Hints  in  Diagnosis In  the  diagnosis  of  syphilides  the  fore- 
going features  collectively  are  of  the  greatest  value.  In  every  case  the 
whole  eruption  should  be  reviewed ;  its  extent,  copiousness,  contiguration, 
and  general  appearance  should  be  carefully  noted  ;  its  mode  of  invasion, 
its  concomitant  symptoms,  and  its  course  should  be  determined  by  careful 
questioning  and  observation.  With  regard  to  the  eruption  itself  we  must 
observe  whether  it  is  composed  of  one  variety  or  of  several  forms  of  lesion, 
and,  if  the  latter,  which  predominates.  For  instance,  in  a  roseolous  erup- 
tion we  judge  of  its  extent,  its  tendency  to  development  in  certain  locali- 
ties, its  contiguration,  whether  the  spots  are  isolated  or  grouped  in  rings; 
then  Ave  consider  whether  the  spots  themselves  are  in  their  early  hyper- 
a;mic  stage,  or  whether  they  have  become  pigmented  or  perhaps  sligiitly 
papular  and  scaly.  By  comparing  the  number  of  erythematous  and  of 
pigmented  spots  we  assure  ourselves  of  the  age  of  the  rash,  and  whether 
its  course  lias  been  rapid  or  chronic.  We  must  also  learn  the  general 
condition  of  the  patient  and  whether  other  tissues  have  been  affected. 

In  case  papules,  pustules,  and  scaling  patches  are  associated  with  ery- 
thematous spots,  we  must  decide  which  lesion  predominates,  and  whether 
they  are  not  mere  phases  of  development  of  the  same  process.  We  may 
perhaps  learn  that  the  red  spots  become  pigmented  and  slightly  papular, 
while  here  and  there  are  papules  which  change  into  pustules,  vesicles, 
ulcers,  or  scaling  spots.  We  observe  whether  the  lesions  have  a  tendency 
to  unite  and  form  patches.  In  this  feature  syphilis  is  peculiar,  differing 
radically  from  most  of  the  simple  eruptions. 

In  case  of  several  varieties  of  lesions  which  may  undergo  various 
changes,  each  one  runs  its  course  quite  distinct  from  the  other.  This  is 
quite  ditfei'ent  from  Avhat  happens  in  simple  polymorphous  eruptions.  We 
may  have  simple  erythematous  patches,  papules  and  pustules  associated, 
but  they  ai"e  related  to  each  other  in  the  develo{)ment  of  one  inflammatory 
process,  and  they  liave  a  tendency  to  blend  and  form  a  homogeneous  erup- 
tion, as  in  eczema  and  scabies.  In  some  cases  of  acne,  papules  and  pustules 
are  scattered  together,  yet  a  bond  of  union  is  always  found  to  exist  between 
them  in  their  inflammatory,  follicular  origin,  while  they  have  other 
features  which  differ  from  those  known  to  be  peculiar  to  syphilis. 

The  Erythematous  Syimiilide. 

(Syn.  Syphilitic  Roseola,  Macular  Syphilide,  Exanthematous  Syphilide, 
Syphilis  Cutanea  Maculosa.) 

The  erythematous  syphilide  is  usually  the  earliest  syphilitic  eruption. 
It  probably  exists  in  all  cases  of  syphilis,  but  may  escape  observation  on 
account  of  its  scantiness,  or  by  reason  of  its  forming  only  a  part  of  an  erup- 
tion which  is  chiefly  papular  or  pustular. 


THE    ERYTHEMATOUS    SYPHILIDE.  517 

The  lesion  consists  of  round  or  oval  spots,  with  distinct  or  irregular  out- 
lines of  an  average  diameter  of  about  one-third  of  an  inch.  Their  color 
varies  from  a  delicate  rosy  pink  to  a  decided  red  or  even  a  purple  line.  In 
some  cases  there  may  be  only  a  mottling  of  the  skin,  or  the  eruption  may 
be  so  faint  as  to  be  invisible  except  on  careful  inspection  or  in  an  oblique 
light.  Exposure  to  cold  brings  the  spots  into  prominence,  while  they  dis- 
appear in  the  general  hypericmia  of  the  surface  from  increase  of  tempera- 
ture, and  show  themselves  more  clearly  in  the  reaction  which  follows.  At 
first  the  spots  may  be  eflfaced  by  pressure,  but  about  the  end  of  the  first 
month  they  may  assume  a  grayish-brown  or  coppery  tint,  which  is  perma- 
nent. This  tint  appears  earlier  in  exposed  regions  and  on  the  legs,  per- 
haps owing  to  peculiar  conditions  of  the  circulation.  Sometimes  the 
eruption  disappears  without  this  change  of  color.  There  is  seldom  either 
elevation  or  scaling  of  the  surfaces  of  the  spots. 

In  mild  forms  of  this  syphilide  there  is  probably  no  other  change  than 
temporary  capillary  stasis  and  occasionally,  in  debilitated  subjects,  hemoi-- 
rhagic  effusion.  In  chronic  cases  a  proliferation  of  cells  occurs  which  is 
described  by  Biesiadecki  as  follows  :  "  We  find  the  walls  of  the  capillaries 
studded  at  this  point  with  numerous  nuclei,  projecting  on  their  inner  and 
outer  surfaces,  and  surrounded  by  a  row  of  cells  here  and  there  interrupted. 
These  cells  exactly  resemble  in  size  and  structure  white  blood-corpuscles 
or  the  cells  of  dermatitis.  They  are  situated  around  the  vessels  in  a  cleai'ly 
bounded  space.  The  adventitia  of  the  vessels  in  the  region  of  the  macule 
incloses  round  and  spindle-shaped  cells.  This  exuberance  of  cells  is 
most  marked  in  the  adventitia  of  vessels  running  towards  the  papillte  ; 
their  calibre  is  contracted,  while  that  of  the  capillaries  in  the  papillae  is 
somewhat  dilated.  Neither  the  cells  nor  the  fibres  of  connective  tissue 
show  any  appreciable  change,  only  here  and  there  granules  of  brownish- 
yellow  pigment  are  interspersed.  Tlie  syphilitic  macule  must  therefore  be 
regarded  as  a  disease  of  the  bloodvessels  as  shown  by  the  increase  of  their 
granular  and  cellular  elements."  Further  microscopic  observations  have 
been  made  by  Kaposi,  who  confirmed  the  occurrence  of  cell-changes  in  tlie 
capillary  walls,  and  also  observed  cell-infiltration  of  the  papillai.  It  is 
quite  [)robable  that  these  combined  changes  occur  in  erythematous  spots, 
which  are  more  or  less  papular. 

Tlie  incomplete  papules,  resulting  from  this  limited  cell-increase,  min- 
gled with  the  hyperaemic  patches,  form  an  eruption  which  has  been  called 
by  Bazin  ''  roseole  papuleuse"  and  by  Fournier  "  roseola  urticata." 

In  very  chronic  eruptions  several  minute  specks  of  darker  tint,  appear 
on  the  surface  of  some  of  the  roseolous  patches,  indicating  a  more  intense 
hyperemia  at  follicular  openings.  They  are  usually  a  little  above  the  level 
of  the  patch  and  are  frequently  traversed  by  a  hair,  and  their  pigmenta- 
tion is  generally  more  persistent  than  that  of  the  surrounding  patch. 
Fournier  calls  this  modification,  "  roseole piquetee,"  or  '■^granular  roseola." 

The  erythematous  syphilide  requires  a  week  or  ten  days  for  its  complete 
development,  but  individual  patches  reach  their  full  size  in  a  day  or  two, 


518  SYPHILIDES. 

juul  show  no  tendency  to  coalesce  or  to  form  circles.  In  rare  cases  of 
"•reat  intensity,  or  from  any  cause  which  stimulates  the  capillary  circula- 
tion, the  whole  body  may  be  invaded  by  tlie  eruption  in  a  single  day. 

The  spots  may  be  first  seen  in  the  vicinity  of  the  umbilicus,  soon  extend- 
ing to  the  thorax,  sometimes  following  the  line  of  the  ribs,  and  finally,  in 
severe  cases,  being  closely  crowded  together  over  a  large  portion  of  the 
surface.  In  exceptional  cases  they  appear  first  on  the  tace.  In  mild 
eruptions  the  spots  are  most  numerous  on  the  sides  of  the  trunk  and  on  the 
inner  surfaces  of  the  extremities.  On  the  genitals  of  either  sex  the  macules 
are  prone  to  hypertrophy,  and  hence  we  frequently  see  condylomata  lata 
coexisting  with  roseolous  patches  in  these  regions.  Similar  changes  are 
noticed  about  the  anus,  the  umbilicus,  the  nose  and  the  mouth,  and  in  tlie 
fold  of  integument  below  the  breasts.  A  limited  number  of  patclies  may 
be  found  on  the  palms  and  soles,  which  may  be  diffuse  or  slightly  elevated 
and  scaly.  The  dorsal  surfaces  of  the  hands  and  feet  are  rarely  invaded. 
A  common  region  is  the  lower  two-thirds  of  the  forearms  and  the  wrists. 
The  neck  is  frequently  exempt,  or  an  eruption  on  the  trunk  may  extend 
by  occasional  spots  along  the  back  of  the  neck  to  the  scalp. 

When  the  iace  is  invaded  the  macules  are  developed  more  freely  about 
the  nose,  niouth,  and  chin,  and  especially  on  the  forehead  at  the  border  of 
the  scalp, ^  where  they  are  often  associated  with  minute  follicular  elevations, 
which  become  crested  with  sebum  and  may  be  mistaken  for  pustules. 
Many  of  the  so-called  "scabs"  on  the  scalp  have  this  origin.  These 
patches  at  the  margin  of  the  scalp  are  often  very  irregular  and  confiuent. 
Tliis  eru}»tion  on  any  ])art  of  the  face  is  usually  covered  by  fine  adherent 
scales  of  epidermis  or  by  thin  yellowish-white  crusts,  which  give  it  a 
smooth,  shiny  appearance. 

The  course  of  the  erythematous  syphilide  is  slow,  and,  except  in  cases 
of  active  invasion,  it  is  not  attended  by  special  irritation  or  heat  of  the 
skin. 

Its  duration  depends  on  the  degree  of  the  hyperajmia  and  on  treatment. 

A  faint  rash  often  disappears  spontaneously,  even  within  a  week,  under 
the  use  of  mercury.  After  pigmentation  has  taken  place,  internal  treatment 
needs  to  be  supplemented  by  the  external  use  of  mercury  in  ointment, 
lotion,  or  still  better  the  vapor  bath. 

A  I'elapse  of  this  syphilide  may  occur  during  the  first  year  of  contagion, 
and  is  generally  less  copious  than  tlie  primary  eruption.  The  macules  are 
more  localized  and  are  likely  to  assume  the  circular  form,  which  is  never 
snen  in  the  initial  eruption,  and  they  are  attended  by  less  febrile  reaction. 
In  certain  cases  as  many  as  three  and  four  recurrences  have  been  observed, 
the  forearms  and  gluteal  regions  being  the  parts  most  often  affected. 

Coexisting  Lesions  and  Symptoms On  account  of  its  early  appearance 

•  The  early  eruptions,  especially  the  papular  syphilide,  are  very  likely  to  form 
a  segment  of  a  circle  at  the  border  of  the  seal]),  which  has  been  called  the  "  corona 
Veticris.''^  It  is  a  mistake  to  suppose  that  the  papular  erujitiou  is  the  ouly  one 
which  may  be  developed  in  this  way. 


THE    ERYTHEMATOUS    SYPHILTDE.  519 

the  erythematous  syphilide  is  often  associated  with  many  other  lesions, 
one  of  which  is  the  fully  developed  initial  lesion.  Indurated  ganglia  may 
also  be  found,  and  hyperajmia  or  mucous  patches  of  the  fauces.  Where 
two  surfaces  of  integument  are  in  contact,  the  confluence  of  erythematous 
spots  may  form  large  inflamed  patches,  sometimes  mistaken  for  intertrigo. 

They  have  sharjily  circumscribed  margins  and  superficially  ulcerated 
surfaces,  which  secrete  a  viscid  offensive  fluid.  They  are  often  accompa- 
nied by  papules  about  the  hair  follicles,  or  even  by  pustules  and  condylo- 
mata lata.  Alopecia  and  affections  of  the  nails  sometimes  occur  at  this 
period.  Slight  periostitis  and,  in  bad  cases,  osseous  affections  may  be 
present.  Superficial  scaling  of  the  palms  or  even  of  the  soles  may  be  ob- 
served. Iritis  is  rarer  than  in  a  general  papular  eruption.  In  a  person 
with  a  long  prepuce  and  of  uncleanly  habits,  patches  of  erythema  on  the 
raucous  membrane  of  the  glans  may  result  in  quite  destructive  ulceration. 

Diagnosis The  diagnosis  of  the  erythematous  syphilide  is  to  be  made 

in  its  form  of  hypera?mic  patches,  in  its  pigmented  condition,  and  in  its 
ringed  form. 

In  its  hyperfemic  stage  it  may  be  mistaken  for  rubeola,  scarlatina,  or 
the  erythema  following  the  ingestion  of  balsams  or  the  use  of  mercury. 

The  mode  of  invasion,  the  absence  of  severe  general  symptoms,  and  the 
circumscribed  and  indolent  character  of  the  rash,  will  usually  enable  us 
to  distinguish  it  from  rubeola  and  scarlatina ;  moreover,  the  presence  of 
catarrhal  and  conjunctival  symptoms  in  the  former,  and  of  gastric  and 
thi'oat  symptoms  in  the  latter,  will  be  of  assistance. 

The  rash  caused  by  cubebs,  copaiba,  tar,  etc.,  is  always  attended  by  high 
fever  and  serious  gastric  disturbance,  and  the  patches  are  many  of  them 
very  large  and  (Edematous,  or  like  the  wheals  of  urticaria.  It  soon  fades 
on  cessation  of  the  exciting  cause. 

An  eruption  may  be  caused  by  either  the  internal  or  external  use  of 
mercury.  It  appears  suddenly  in  the  form  of  very  large  hypera^mic 
patches,  of  a  bright  red  color,  which  soon  become  dull  and  quickly  fade, 
leaving  no  trace.     It  is  not  infrequently  mistaken  for  a  relapsing  eruption. 

One  of  the  most  frequent  errors  in  the  diagnosis  of  syphilitic  eruptions 
is  that  of  confounding  tiie  pigmentary  stains  of  the  erythematous  syphilide 
with  tinea  versicolor.  They  somewliat  resemble  each  other  in  color,  but 
that  of  tinea  is  more  yellow,  and  many  of  its  patches  are  very  large,  and 
they  are  always  accompanied  by  some  extremely  small  ones.  Tinea  is, 
moreover,  slightly  pruritic,  and  its  scales  contain  the  microsporon  furfur. 
The  patclu's  of  tinea  are  always  found  over  the  sternum,  where  syphilitic 
eruptions  are  rare,  and  they  are  much  less  scattered  than  those  of  the 
syphilide. 

In  rare  instances  of  slight  elevation  and  scaliness,  the  rings  of  the  ery- 
thematous syphilide  may  be  mistaken  for  tinea  circinata.  The  syi)hilitic 
rings  are  much  more  numerous,  do  not  increase  in  size,  and  the  area  of  in- 
closed skin  is  unaltered.  The  scales  of  tinea  circinata  always  contain  tlie 
parasite  tricophyton  tonsurans. 


620  SYPHILIDES. 

The  Papular  Syphilides. 

This  most  important  dermal  lesion  of  syphilis  is  composed  of  cii'cum- 
scribed  infiltrations  into  the  superficial  layers  of  the  skin,  and. presents  two 
varieties,  the  conical  or  miliary  and  the  lenticular  or  Jlat. 

It  may  constitute  the  first  symptom  of  the  secondary  stage,  or  it  may 
be  combined  with  the  erythematous  syphilide.  In  relapses  it  frequently 
occurs  alone,  or  is  by  far  the  larger  proportion  of  a  recurring  eruption.  It 
may  be  seen  even  in  the  tertiary  stage,  and  it  merges  into  the  tubercular 
syphilide  by  intermediate  grades  of  papulo-tubercles.  Some  of  these  in- 
termediary papules  are  attended  by  an  epidermal  proliferation,  and  have 
therefore  sometimes  been  erroneously  called  "squamous  syphilides."  The 
various  changes  of  form  and  distribution  which  the  papules  undergo  some- 
times gives  them  a  strong  resemblance  to  simple  skin  lesions. 

7'he  Miliary  Papular  Syphilide. 

The  miliary  papular  syphilide  has  two  distinct  varieties,  one  composed 
of  large  and  the  other  of  small  papules. 

Some  of  the  small  papules  are  about  the  size  of  a  pin's  head,  wliile 
others  are  two  or  tliree  times  as  large.  They  consist  of  distinctly  limited, 
conical  or  rounded  elevations  of  the  skin,  sometimes  umbilicated,  and,  in 
their  early  stages,  they  have  a  deep  pinkish-red  color.  When  forming  the 
first  eruption  of  the  secondary  period,  or  an  early  relapse,  they  are  distri- 
buted over  the  whole  body,  sometimes  closely  packed  together,  and  par- 
ticularly copious  on  the  forehead,  about  the  nose  and  chin,  on  the  back  of 
tlie  neck,  on  the  outer  surfaces  of  the  extremities,  and  upon  the  scapular 
and  gluteal  regions.  The  papules  may  be  arranged  in  groups,  in  the  form 
of  circles  or  segments  of  circles,  or  like  the  letter  S  or  the  figure  8.  Some- 
times the  papules  com[)Osing  rings,  which  may  have  a  diameter  of  half  an 
inch  or  two  inches,  fuse  together  and  lose  their  individual  shape.  The 
circular  form  is  assumed  only  in  the  regions  referred  to,  while  elsewht^i-e 
papules  may  be  seated  without  definite  order. 

In  a  general  eruption  papules  may  be  seen  on  the  backs  of  the  hands 
and  upon  the  scrotum  and  ]ienis,  where  they  usually  become  excoriated 
and  are  transformed  into  condylomata.  Unlike  the  flat  papules,  these  are 
rarely  accompanied  by  condylomata  about  the  anus  in  the  male  and  the 
vulva  in  the  female.  After  frequent  relapses  the  papules  are  generally 
less  numerous  and  less  confined  to  particular  regions,  while  the  ring  form 
becomes  a  more  prominent  feature.  When  the  erui)tion  occurs  late  in  tiie 
secondary  period  it  may  be  seen  in  but  one  region,  and  may  even  be  un- 
symmetrical. 

This  eruption  usually  begins  about  the  face  and  neck  and  is  fully  devel- 
oped at  the  end  of  two  weeks.  In  some  instances  its  evolution  is  so  rapid 
that  it  has  been  called  tlie  "  acute  papular  syphilide."  In  late  relapses 
the  papules  appear  as  slowly  as  any  other  syphilitic  eruption.  Many  of 
the  papules  are  seen  to  be  at  the  openings  of  follicles,  a  feature  which  is 
more  noticeable  in  this  than  in  any  other  lorm  of  syi)hilitic  papule. 


THE    PAPULAR    STPHILIDES.  521 

After  their  complete  development  the  papules  remain  unchanged  for  a 
time.  In  some  cases  new  papules,  and  exceptionally  pustules,  appear 
among  the  old  ones.  Soon  their  color  changes  to  a  sombre  brown,  and 
finally  to  a  coppery  hue.  Small  scales  of  epidermis,  frequently  in  the 
form  of  rings  which  correspond  to  the  margins  of  papules,  are  detached  by 
the  infiltrative  process  beneath.  This  feature  was  regarded  by  Biett,  who 
first  described  it,  of  considerable  diagnostic  importance.  A  marked  ten- 
dency to  further  desquamation  is  observed  only  in  chronic  cases  and  in 
regions  where  the  epidermis  is  thick  ;  it  is  sometimes  so  decided  as  to  re- 
semble the  early  stage  of  psoriasis. 

Frequently  a  few  of  the  papules  are  converted  into  vesicles  or  pustules 
by  the  accumulation  at  their  apices  of  a  minute  quantity  of  serum  or  pus. 
They  may  remain  in  this  condition  for  a  long  time.  Generally  the  fluid 
dries  and  forms  a  minute  crust  which  may  fall  oW  spontaneously,  leaving 
the  papules  apparently  in  their  elementary  state.  In  some  cases  pustules 
form,  which  may  dry  or  become  ulcers. 

Jullien,  (^Mal.  veneriennes,  p.  716)  says  that  sometimes  no  fluid  escapes 
on  puncture  of  the  apparently  vesicular  apex  of  one  of  these  papules.  In 
such  case  he  thinks  the  appearance  is  due  to  "  oedematous  softening,  of 
the  neoplasm."  We  have  observed  this  feature  less  frequently  than 
Jullien. 

The  occurrence  of  distinct  groups  of  papules  which  have  undergone  these 
changes,  generally  on  the  face,  about  the  mouth,  and  on  the  forearms  and 
backs  of  the  hands,  has  perhaps  led  some  authors  to  admit  the  existence 
of  a  vesicular  syphilide. 

In  some  instances  papules  about  the  nose  and  mouth  have  a  yellow 
crust  composed  of  sebaceous  matter  from  the  tbllicles  around  which  they 
are  developed.  On  account  of  the  appearance  of  the  crust  and  the  super- 
ficial infiltration  of  the  papules  the  case  might  be  mistaken  for  one  of 
seborrhoea. 

When  uninfluenced  by  treatment  the  course  of  the  eruption  is  chronic. 
In  its  early  stage  it  yields  slowly  to  treatment,  but  after  long  persistence 
it  becomes  very  obstinate  and  requires  local  as  well  as  general  treatment. 
Its  rapid  and  early  disappearance  is  desirable,  since  permanent  atrophic 
spots,  like  those  of  variola,  remain  after  a  lesion  which  has  had  a  long 
existence.  These  spots  are  pigmented,  and  they  become  white  ordy  after 
several  months.  Pigment  may  also  be  deposited  when  atrophy  has  not 
occurred. 

The  diagnosis  is  generally  easy,  at  least  in  the  early  stage.  The  eruption 
may  be  mistaken  for  the  punctate  form  of  psoriasis,  or  for  certain  cases  of 
lichen  pilaris  and  lichen  planus. 

In  psoriasis  the  papules  tend  to  form  patches  of  an  inch  or  more  in 
diameter,  and  the  scales  are  copious,  silvery  and  imbricated. 

Lichen  pilaris  is  an  inflammatory  affection,  chiefly  of  hairy  regions,  and 
is  accompanied  by  intense  pruritus,  and  the  papules  often  form  patches  of 
thickened  skin. 

In  hchen   i)lanus  the  pajjules  are  flatter,  less  uniform,  mon;  commonly 


522  STPHILIDES. 

umbilicated,  are  always  pruritic,  and  are  more  likely  to  lose  their  original 
character  by  confluence. 

Moreover,  with  the  syphilide  we  have  the  specific  history  and  possibly 
the  coexistence  of  other  and  distinctive  lesions. 

In  addition  to  the  small  conical  papules,  there  are  others  as  large  as 
peas,  markedly  conical,  and  having  an  elevation  of  about  a  line.  They 
rarely  ajipear  in  large  numbers,  or  constitute  an  early  general  eruption, 
but  are  found  at  the  time  of  a  relapse  mingled  with  tlie  smaller  papules, 
w-ith  pustules,  or  with  an  erythematous  syphilide.  They  are  more  pro- 
fuse on  the  back  and  buttocks  than  elsewhere.  Their  evolution  is  slow. 
Their  bright  red  color  soon  fades,  and  they  are  quite  apt  to  pustulate  and 
form  ulcers.  They  have  no  orderly  arrangement  either  in  grou[)s  or  in 
circles.  They  yield  more  readily  to  treatment  than  the  small  papules, 
and  seldom  leave  atrophic  and  coppery  spots. 

This  form  of  papular  syphilide  may  be  mistaken  for  acne,  especially  on 
account  of  its  appearance  on  the  back.  In  acne  the  lesions  are  most 
abundant  about  the  face  and  shoulders;  they  vary  greatly  in  size,  and 
are  accompanied  by  more  hypera^mia.  Acne  usually  begins  about  puberty, 
and  has  a  history  of  many  recurrences. 

y%e  Lenticular  Papular  Syphilide. 

There  are  two  varieties  of  flat  papules  caused  by  syphilis — the  small 
and  the  large.  The  small  papules  frequently  occur  in  the  lorm  of  a 
general  eruption ;  this  is  rarely  true  of  the  large  papules,  which  are  usually 
seen  concurrently  .with  a  small  papular  eruption,  an  erythematous,  or 
perhaps  a  pustular  syphilide.  These  two  forms  of  papules  present  striking 
differences. 

The  small  Flat  Papular  Syphilide. 

The  small  papules  begin  as  minute  red  spots,  which  rapidly  increase 
until  tliey  i-each  a  diameter  of  one-eighth  to  one-fourth  of  an  inch,  and 
an  elevation  of  one-third  to  one-half  a  line.  They  are  either  round  or 
oval,  have  flat  surfaces,  and  rounded  and  distinctly  limited  margins.  A 
few  papules  may  be  slightly  depressed  at  the  centre,  but  we  do  not  find 
them  surrounding  follicular  openings  or  pierced  with  hairs.  In  the  early 
and  general  eruptions  the  pixpules  are  scattered,  and  show  no  tendency  to 
fuse  together.  In  relapses  they  are  less  numerous,  and  are  more  likely  to 
be  grouped  and  arranged  in  a  circular  form. 

Mode  of  Distribution — The  papules  are  first  seen  about  the  shoulders, 
or  at  the  back  of  the  neck,  or  on  the  sides  of  the  thorax,  and  are  soon 
followed  by  others  on  the  forehead  at  the  margin  of  the  hairy  scalp,  with 
perhaps  a  few  on  the  face,  about  the  nose  and  mouth,  and  on  the  anterior 
surface  of  the  neck,  rarely  on  the  ears.  At  the  same  time,  or  soon  after, 
the  trunk  is  invaded,  i)articularly  the  back,  and  the  papules  may  follow 
the  line  of  the  ribs.  As  a  rule,  the  supra-  and  infra-clavicular  regions 
are  wholly  spared.     The  papules  are  copious  in  the  hypogastric  region  ; 


THE    PAPULAR    SYPHILIDES.  523 

but  few  are  seen  over  the  sternum ;  they  are  numerous  over  the  anterior 
surface  of  the  shoulders,  but  comparatively  sparse  on  the  outer  surface  of 
the  arms,  while  they  tire  more  numerous  on  the  inner  or  flexor  surfaces, 
especially  near  the  joints.  Few  are  seen  on  the  dorsum  of  the  hands, 
while  the  palms  are  more  freely  supplied.  They  are  unusually  numerous 
on  the  gluteal  regions,  and  are  not  infrequently  found  upon  the  penis,  the 
mons  Veneris,  and  in  the  inguinal  region.  They  are  more  plentiful  on 
the  inner  than  the  outer  aspects  of  the  thighs,  and  they  either  do  not  ex- 
tend below  the  knees,  or  are  sparsely  distributed  upon  the  inner  surfaces 
of  the  legs  and  sometimes  upon  the  soles.  The  face  is  spared  by  this 
syphilide  more  frequently  than  by  the  small  miliary  variety.  It  sometimes 
assumes  the  form  of  the  so-called  "corona  Veneris,"  and  occupies  the  fore- 
head where  the  hat  presses ;  it  is  seen  upon  the  alas  nasi  and  about  the 
mouth,  and  shows  a  marked  tendency  to  development  near  the  junction  of 
the  skin  with  mucous  membranes.  In  rare  cases  the  papules  are  very 
copious  and  hypertrophic  upon  the  face,  where  they  cause  a  peculiar  ex- 
pression, similar  to  that  sometimes  seen  in  true  leprosy,  which  is  called 
by  some  authors  "syphilitic  leontiasis."^ 

The  color  of  the  small  flat  papules  varies  in  diflferent  regions  of  the  body, 
and  in  different  persons.  In  their  early  stage  it  is  a  pinkish-red,  which 
soon  becomes  brownish  or  coppery;  this  change  occurs  first  on  the  face, 
especially  the  forehead,  then  on  the  legs.  In  persons  with  delicate  skin 
or  feeble  circulation  the  color  is  at  fiist  very  light  red,  which  changes  to  a 
light  yellow  tinged  with  brown.  On  the  legs,  the  papules  sometimes 
become  of  a  purple  color,  owing  to  blood  stasis  or  effusion.  This  condition 
may  be  general  in  broken-down  or  scorbutic  subjects.  In  rare  cases  some 
of  the  papules  on  the  face  are  of  the  color  of  the  normal  skin  ;  they  are 
always  accompanied  by  others  which  are  colored.  On  parts  freely  supplied 
with  sebaceous  follicles  some  of  the  papules  are  covered  by  a  thin  yellowish 
crust,  which,  being  easily  removed,  exposes  a  shining  surface  with  no 
evidence  of  ulceration.  This  crust,  formed  of  epithelium  and  sebaceous 
matter,  is  generally  coextensive  with  the  papule. 

There  is  a  marked  difference  in  the  amount  of  scaling  of  the  papules  in 
different  persons  and  in  different  parts  of  the  body.  The  epithelium  at  the 
border  of  fully  developed  papules  may  be  detached  and  form  a  fringe 
around  them,  as  in  the  case  of  miliary  papules.  The  scales  on  the  surface 
of  the  papules  are  generally  small,  adherent,  and  not  of  the  silvery  white 
color  of  those  in  psoriasis.  On  surfaces  where  the  epidermis  is  thick  the 
papules  are  not  infrequently  lost  in  a  desquamating  patch  ;  this  is  apt  to 
be  the  case  with  late  papular  syphilides  of  the  palms  and  soles,  which  have 
received  the  name  "  syphilitic  psoriasis." 

These  papules  are  of  softer  consistence  than  the  small  miliary  papules, 
and  do  not  give  to  the  finger  the  rough,  firm  sensation  of  the  latter. 

In  exceptional   cases  a  peculiar   necrotic  change  takes  place  upon  the 

'  A  similar  but  more  marked  condition  obtoins  also  in  certain  tubercular  syphi- 
lides. 


524  SYPHILIDES. 

surface  of  many  of  the  papules.  Their  epidermis  is  thrown  off  either  by 
scaling  or  by  molecular  decay,  and  is  replaced  by  a  dirty-brownish  mem- 
brane of  a  fibrous  nature,  wiiich  is  removed  in  fragments  or  in  mass,  and 
exposes  a  granular  ulcerated  surface.  This  seems  to  be  a  diphtheritic 
deposit.  We  have  seen  but  few  instances  of  this  complication,  and  only  in 
cachectic  subjects. 

Like  all  other  syphilitic  papules  these  disappear  by  absorption  of  their 
cell  elements.  Under  the  use  of  mercury  the  process  is  rapid  ;  otherwise 
the  papules  slowly  flatten,  and  are  gradually  replaced  by  copper-colored 
spots  of  pigment,  which,  tliough  quite  persistent,  are  not  so  obstinate  as 
those  left  by  the  small  miliary  papule.  Although  internal  treatment 
causes  the  absorption  of  tlie  papules,  it  is  almost  powerless  against  the  pig- 
mentation left  by  them. 

As  a  rule  atrophy  of  the  skin  does  not  follow  the  absorption  of  the  small 
flat  papules,  although  in  very  chronic  cases,  minute  depressed  cicatrices 
result  from  absorption  of  some  of  the  cells  of  the  skin  itself,  as  well  as  of 
those  of  the  papules.  This  occurrence  is  more  common  on  the  face  than 
elsewhere.  ' 

The  invasion  of  this  syphilide  is  usually  subacute,  but  it  may  be  has- 
tened by  eiccessive  heat,  hot  baths,  alcoliolic  drinks,  or  similar  influences. 
It  never  appears  as  rapidly  as  the  small  miliary  papular  eruption,  and  is 
never  accompanied  by  itching.  A  period  of  a  week  or  ten  days  usually 
elapses  before  the  eruption  is  complete  The  number  of  papules  varies; 
when  this  syphilide  is  the  first  manifestation  upon  the  skin,  as  it  is  in  about 
twelve  per  cent,  of  the  cases,  the  papules  are  very  numerous,  so  that  the 
tip  of  the  finger  can  scarcely  be  laid  upon  the  skin  without  touching  one 
or  more  of  them.  This  may  be  true  also  in  a  first  relapse  following  an 
erythematous  syphilide. 

Although  the  eruption  may  be  less  copious  it  is  usually  widely  dis- 
tributed. Relapses  are  quite  amenable  to  treatment.  Uninfluenced  by 
mercurials  this  syphilide  is  very  indolent ;  while  some  papules  are  under- 
going resolution,  new  ones  appear,  so  that  all  stages  of  development  may 
be  represented  in  a  single  case.  Treatment  quickly  dispels  the  eruption 
and  influences  the  copiousness  of  succeeding  lesions.  This  fact  is  partic- 
ularly noticeable  in  private  practice,  where  patients  seek  advice  early  ; 
with  careless  persons,  on  the  contrary,  a  relapse  may  be  extensive  and 
profuse. 

A  relapse  of  this  syphilide  may  be  expected  at  any  time  within  two 
years  after  infection.  In  one  occurring  after  the  sixth  month  the  papules 
are  limited  in  number  and  extent,  and  their  color  is  generally  darker  than 
that  of  an  early  rash.  A  few  papules  may  appear  over  the  trunk,  upon  the 
face  and  on  the  inner  aspect  of  the  limbs  near  the  joints,  either  scattered 
or  in  a  ringed  form.  In  relapses  of  this  syphilide  the  papules  tend  to 
appear  on  the  elbows  and  knees,  sometimes  in  the  form  of  circles  or  seg- 
ments of  circles,  and  perhaps  accompanied  by  papules,  either  scattered  or 
grouped  in  rings,  about  the  shoulders  and  trunk.  Psoriasis  presents  cer- 
tain similar  features  and  is  particularly  prone  to  appear  in  these  regions. 


THE  LARGE  FLAT  PAPULAR  SYPHILTDE.  525 

Tlie  syphilide  may  be  found  upon  the  elbows  alone;  it  is  rather  unusual  to 
see  it  upon  the  knees  and  not  upon  the  elbows.  Generally  a  few  papules 
are  scattered  over  the  body. 

Careful  examination  of  the  patches  shows  that  the  rings  are  formed 
either  by  fusion  of  the  papules  or  by  their  interrupted  distribution.  With 
care  it  is  seen  that  the  basis  of  the  eruption  is  papular,  and  that  there  is 
no  morbid  change  in  the  encircled  area  of  skin.  This  is  quite  different 
from  the  condition  in  psoriasis,  in  which  a  papule  increases  centrifugally, 
until  it  reaches  a  diameter  of  an  inch  or  more,  when  evolution  takes  place 
at  the  centre  of  the  lesion,  the  periphery  remaining  unchanged. 
.  Other  points  of  distinction  are  yet  to  be  spoken  of. 

Coexisting  Symptoms  and  Lesions. — When  this  eruption  is  the  first 
dermal  manifestation,  it  is  always  accompanied  by  several  others,  such 
as  buccal  and  pharyngeal  lesions,  swelling  of  ganglia,  alopecia,  pains  of 
various  kinds  and  perhaps  iritis.  The  latter  affection  occurs  more  fre- 
quently with  this  than  with  any  other  form  of  papular  syphilides.  Having 
a  marked  tendency  to  relapse  at  any  time  during  the  secondary  period,  this 
syphilide  may  coexist  with  any  of  the  manifestations  peculiar  to  tliat  period. 

Diagnosis. — General  eruptions  of  this  syphilide  are  so  peculiar  in  the 
distribution,  shape,  and  appearance  of  the  papules,  and  are  so  often  accom- 
panied by  other  syphilitic  symptoms  that  the  diagnosis  is  usually  clear. 
In  some  sparse  eruptions  which  are  especially  chronic  and  in  which  papules 
are  exti'aordinarily  scaly,  there  may  be  some  doubt  between  syphilis  and 
psoriasis  in  its  guttate  stage.  The  latter  disease  is  essentially  scaly  and 
the  patches  are  not  uniform  in  size;  it  generally  begins  in  early  life  and 
recurs  in  subjects  apparently  healthy  ;  its  scales  are  silvery,  imbricated 
and  plentiful,  while  those  of  syphilis  are  of  a  more  sombre  hue,  are  not 
imbricated,  and  usually  not  very  copious.  In  psoriasis  there  is  a  history  of 
numerous  similar  eruptions,  in  syphilis  there  may  be  relapses  of  similar 
papules,  but  they  are  likely  to  be  less  copious  and  more  localized  with  each 
succeeding  outburst.  In  syphilis  there  is  the  history  of  tlie  initial  or  other 
lesion  and  perhaps  the  coexistence  of  other  symptoms  and  usually  a  con- 
dition of  ill  health.  Arsenic  cures  psoriasis  but  not  syphilis;  syphilis  is 
curable  by  mercury,  an  agent  which  is  powerless  in  psoriasis. 

In  those  cases  in  which  the  papules  are  develo{)ed  in  a  ringed  form  upon 
the  elbows  and  knees,  the  general  distinctions  just  given  apply.  On  ex- 
amination of  the  rings  or  segments  of  rings  they  are  found  to  be  formed 
by  the  fusion  of  individual  papules.  They  are  less  scaly,  more  copper- 
colored,  and  more  sharply  defined  than  the  rings  of  psoriasis,  whicli  are 
formed  by  absorption  of  the  centre  of  a  circular  patch  and  which  continue 
to  increase  in  diameter. 

The  large  Flat  Papular  Si/philide. 

Tiie  large  flat  syphilitic  papules  are  either  round  or  oval  and  have  a 
diameter  of  three-eighths  to  one-half  of  an  inch,  and  exceptionally  of  fully 


526  SYPHILIDES. 

one  inch.  They  begin  as  minute  spots,  whicli  as  a  rule  rapidly  increase. 
Their  surface  is  flat,  but  occasionally  there  is  a  well-marked  sloping  de- 
pression at  the  centre.  They  are  distinctly  elevated,  with  rounded,  sharply- 
defined  edges.  A  few  small  adherent  scales  lie  upon  the  surface,  and  at 
the  margins  of  the  papules  an  epidermal  fringe  or  rim  m.ay  be  seen.  They 
generally  have  a  decidedly  red  color,  which  soon  becomes  coppery.  In 
rare  cases  they  are  bright  crimson  red,  and  exceptionally  they  have  a  deep 
purplish-red  tint.  They  run  a  chronic  course,  and  cause  neither  pain  nor 
itching.  The  surfaces  of  the  papules  in  rare  instances  undergo  superficial 
necrosis  and  become  covered  with  a  thin,  dirty-looking  diphtheroid  mem- 
brane. Such  an  occurrence  is  always  indicative  of  a  depressed  condition 
of  the  system,  and  of  a  severe  form  of  the  disease. 

This  eruption  occurs  under  a  variety  of  circumstances.  In  some  in- 
stances a  few  papules  may  be  found  with  an  erythematous  syphilide  or  an 
eruption  of  small  flat  papules  on  the  foi-ehead,  the  neck,  and  about  the 
genitals.  In  rare  cases  this  syphilide  is  the  first  eruption,  and  it  then 
resembles  the  small  flat  variety  in  its  mode  of  a])pearance  and  its  course. 
It  occurs  upon  the  palms  and  soles  with  about  the  same  frequency  as  the 
latter,  and  in  these  regions  it  may  develop  the  so-called  palmar  and  plantar 
psoriasis.  When  occurring  as  a  first  general  rash,  this  syphilide  shows  no 
tendency  to  a  circular  arrangement,  and,  although  the  papules  may  be 
more  closely  aggregated  on  such  parts  as  the  face,  neck,  shoulders,  inguinal 
and  gluteal  regions,  and  near  joints,  they  do  not  coalesce  except  in  parts 
continuously  irritated.  Owing  to  irritation  their  area  sometimes  becomes 
greatly  increased. 

In  general  this  syphilide  belongs  to  the  middle  and  late  periods  of  the 
secondary  stage,  and  is  with  good  reason  classed  by  some  French  authors 
as  an  intermediary  syphilide.  While,  therefore,  it  is  rarely  observed  as. 
the  first  rash,  it  is  often  met  with  as  late  as  the  second  and  even  the  third 
year  of  syphilis.  As  a  rule  the  earlier  its  appearance  the  more  copious  is 
the  eruption.  Appearing  on  the  subsidence  of  a  first  general  rash,  it  may 
consist  of  quite  a  large  number  of  papules  scattered  irregularly  over  ihe 
body;  such  a  rash  may  be  composed  of  less  than  two  hundred  papules,  or 
even  one  third  that  number.  Provided  treatment  is  followed  relapses  are 
composed  of  even  a  more  limited  number  of  papules,  which  then  show  a 
tendency  to  appear  on  the  palms  and  soles,  on  the  face,  abdomen  and  near 
joints,  seldom,  however,  in  an  annular  form.  About  the  beginning  of  the 
second  year,  sometimes  later,  the  distribution  of  this  syphilide  is  even 
more  limited.  A  few  papules  appear  on  the  arms  or  palms,  run  a  chronic 
course,  and  are  followed  by  a  few  on  the  abdomen,  thighs,  or  forehead.  In 
late  eruptions,  where  the  papules  are  so  few,  they  are  often  much  larger 
than  those  of  earlier  stages,  though  they  rarely  exceed  a  diameter  of  one 
inch.  In  these  cases  the  term  papulo-tubercle  is  perhaps  more  strictly 
expressive  of  the  character  of  the  lesion. 

When  seated  on  the  face  and  on  parts  freely  sup[)lied  with  sebaceous 
follicles,  as  in  the  case  of  the  small  fiat  papules,  thin,  yellowish,  non-ad- 
herent crusts  are   sometimes  observed  on   the  surfaces  of  these  papules. 


THE  LARGE  PLAT  PAPULAR  SYPHILIDE.  52t 

Not  infrequently  the  margins  of  some  of  them  become  elevated  into  dis- 
tinct rims.  Again  an  annular  crust,  of  a  dirty  yellow  color,  may  occupy 
the  periphery  of  a  papule.  Sometimes  this  rim  is  so  yellow  as  to  give  the 
impression  that  it  is  comjiosed  of  pus,  but  its  removal  shows  no  ulceration 
beneath,  and  no  pus-cells  can  be  found  in  it.  Exceptionally  superficial 
ulceration  may  occur  on  some  of  the  papules,  which,  in  broken-down  sub- 
jects, are  sometimes  entirely  converted  into  ulcers.  Sometimes,  on  freely 
movable  parts,  superficial  or  deep  fissures  may  form. 

A  rai*e  metamorphosis  of  this  syphilide  is  sometimes  seen.  The  papules 
become  somewhat  larger  and  more  elevated.  At  first  their  surface  is 
slightly  granulated,  the  appearance  suggesting  an  extraordinary  swelling 
of  the  papillae  cutis.  The  surface  soon  looks  warty  and  resembles  a  rasp- 
berry. The  prominences  are  smooth  and  red,  and  vary  greatly  in  size, 
and  between  them  there  may  be  slight  ulcerations,  from  which  escapes  a 
secretion,  which  dries  and  forms  a  crust.  Sometimes,  when  copious,  the 
secretion  has  a  sickening  odor.  When  thus  hypertrophied  these  papules 
may  be  elevated  to  the  extent  of  two  or  three  lines  or  more  :  their  surface 
may  be  level  or  markedly  rounded.  This  condition  is  most  prone  to  occur 
upon  the  face,  on  the  scalp,  about  the  shoulders  and  near  the  genitals. 
When  thus  changed  this  syphilide  has  received  the  names  "  framboesoid," 
"■  vegetating,"  and  "  verrucous."  The  extent  of  the  process  varies,  in 
some  cases  being  limited  to  a  few  papules. 

A  similar  feature  is  sometimes  observed  on  the  surface  of  flat 
condylomata,  and  in  a  more  hypertrophic  form  on  some  syphilitic  tu- 
bercles. 

Upon  surfaces  that  are  in  coaptation  or  covered  with  moisture,  as  be- 
tween the  toes,  around  the  navel,  at  the  margin  of  the  nostril,  and  on  the 
perinaeum,  these  papules  may  become  superficially  excoriated  or  trans- 
formed into  condylomata  lata.  This  is  well  seen  in  some  cases  of  papules 
on  the  thighs  of  women.  Those  on  the  lower  part  are  simply  scaly,  those 
near  the  genitals  are  superficially  eroded  and  emit  an  offensive  secretion, 
while  those  on  the  vulva  are  truly  condylomatous. 

Under  mercurial  treatment  the  papules  composing  this  syphilide  are,  as 
a  rule,  slowly  absorbed,  a  more  or  less  deeply  pigmented  spot  being  left. 
The  earlier  treatment  is  begun,  the  less  in  degree  will  be  the  resulting 
pigmentation.  The  later  and  more  scattered  eruptions  are  often  more 
rebellious.  They  remain  indolent,  causing  more  or  less  desquamation, 
in  which  feature,  as  well  as  in  their  color,  they  sometimes  resemble 
psoriasis. 

Not  uncommonly,  in  the  retrogressive  stage  of  these  papules,  particu- 
larly in  late  eruptions,  absorption  of  the  centre  of  the  lesion  occurs,  leaving 
a  ring  which  may  be  scaly,  and  which  is  itself  finally  absorbed  without 
showing  any  tendency  to  centrifugal  increase. 

When  occurring  as  the  first  general  eruption,  this  syphilide  coexists  with 
the  numerous  symptoms  peculiar  to  the  early  period.  When  of  later  oc- 
currence it  is  not  infrequently  accompanied  by  pustular  eruptions  on  hairy 
parts,  iritis,  alopecia,  onychia  or  perionychia,  condylomata  and  often  by 


528  SYPHILTDES. 

cachexia.  "When  of  very  late  appearance  it  may  be  the  only  manifestation 
of  the  disease,  and  it  often  recurs  in  a  limited  degree,  to  be  finally  replaced 
by  lesions  of  the  tertiary  period. 

Prognosis The  early  appearance  of  this  sypliilide  indicates  an  active 

and  severe  form  of  syphilis,  and  calls  for  prompt  and  careful  treatment, 
otherwise  the  supervention  of  cachexia  and  of  tertiary  lesions  may  be  ex- 
pected. A  relapse  of  the  eruption  indicates  continued  activity  of  the  dis- 
ease. As  to  the  erui)tion  itself,  its  disappearance  is  merely  a  question  of 
time  and  of  treatment. 

Diagnosis. — A  general  eruption  of  this  sypliilide  presents  such  distinc- 
tive features  that  errors  in  diagnosis  are  scarcely  possible.  Where  it  occurs 
in  limited  numbers  and  runs  a  chronic  course,  particularly  when  there  are 
several  outbursts  of  papules  at  short  intervals,  no  other  lesions  being  visi- 
ble, it  may  be  mistaken  for  psoriasis.  The  question  may  be  still  further 
complicated  by  the  appearance  of  papules  upon  the  elbows  and  knees.  A 
distinction  can,  however,  generally  be  made  by  attention  to  certain  points. 
In  syphilis  the  papules  have  a  uniform  size  not  seen  in  psoriasis ;  in  psori- 
asis the  spots  are  likely  to  blend  and  form  gyrate  patches,  while  in  syphilis 
they  gradually  pass  away  after  reaching  maturity.  The  color  of  the 
psoriatic  patches  is  pinkish  or  deep  crimson  ;  that  of  the  syphilitic  papules 
is  deep  brown  or  dull  crimson.  It  must  be  confessed,  however,  that  a 
diagnosis  must,  in  some  cases,  be  established  by  other  features.  The 
scales  of  the  syphilitic  papules  are  not  as  copious  and  usually  not  as  silvery 
as  those  of  psoriasis ;  tliey  are  simply  more  or  less  adherent  flakes  of 
epidermis.  By  scraping  a  patch  of  psoriasis  much  epidermal  debris  is 
collected,  and  there  is  exposed  either  a  shiny,  thin  pellicle  covering  the 
patch,  or  a  granular  bleeding  surface.  Similar  treatment  of  a  syphilitic 
papule  gives  much  less  epidermal  debris,  and  shows  that  we  are  tearing  a 
solid  tissue.  In  tlie  ringed  form,  from  absorption  of  the  centre  of  the 
papules,  the  resemblance  to  psoriasis  is  sometimes  striking,  but  the  scanti- 
ness of  the  scaling,  the  uniformity  in  size  of  the  rings,  and  their  stationary 
condition  are  in  contrast  with  the  abundant  scaling,  the  varying  size  of 
the  rings  and  the  tendency  to  centrifugal  growth  and  fusion  seen  in  psoriasis. 
The  sharply  defined  border  of  syphilitic  papules  is  seldom  observed  in 
psoriasis.  Moreover,  in  syphilis  there  is  a  history  of  some  other  symp- 
tom or  lesion,  or  there  may  be  other  specific  lesions  on  the  body  at  the 
time.  There  may  also  be  cachexia  in  syphilis,  while  patients  with  })Soriasis 
are  generally  remarkably  healthy.  The  age  of  the  patient  is  sometimes  a 
point  of  importance.  As  a  rule  psoriasis  begins  in  early  life,  and  only 
exceptionally  after  puberty.  The  sypliilide  is  more  common  after  ])uberty 
on  account  of  the  more  frequent  occurrence  of  syphilis  after  that  period. 
Finally,  mercurial  treatment  has  no  effect  upon  psoriasis,  while  it  is 
especially  beneficial  in  this  form  of  syphilide. 


SYPniLIDE    OF    THE    PALMS    AND    SOLES.  529 

Scaling  Papular  Syphilide  of  the  Palms  and  Soles.      (^Syphilitic 
Psoriasis  of  tiie  Palms  and  Soles.) 

Papular  sypliilides  of  the  palms  and  soles  are  often  peculiar  an<l  difficult 
of  diagnosis.  They  may  occur  at  any  time  in  the  secondary  period,  or 
may  coexist  with  tertiary  lesions ;  they  run  a  chronic  course,  unaccompa- 
nied by  pain  and  itching,  and  are  generally  rebellious  to  internal  treat- 
ment. 

The  erythematous  syphilide  is  often  developed  on  the  palms  in  scattered 
spots,  which  have  a  deep  red  color,  are  slightly  elevated,  and  covered  by  a 
layer  of  epidermis.  In  favorable  cases,  subjected  to  treatment,  scaling 
soon  occurs,  leaving  a  smooth,  rosy,  slightly  depressed  surface,  surrounded 
by  an  undermined  rim  of  epidermis.  The  mode  of  development  of  these 
spots,  when  not  treated,  will  be  described  later. 

In  a  general  eruption  of  flat  papules  a  few  sometimes  occur  in  the  hollow 
of  the  palms  and  soles.  They  are  small,  decidedly  elevated,  and  have  a 
deep  red  or  purple  color.  Exceptionally  they  are  very  numerous  in  the 
above  regions.  They  disappear  under  treatment,  but,  if  left  to  themselves, 
they  become  chronic. 

In  some  cases,  usnally  early  in  the  secondary  period  and  coexisting  with 
dermal  or  other  manifestations,  or  perhaps  being  the  only  evidence  of 
syphilis,  a  varying  number  of  small,  firm,  hard,  colorless  elevations  or 
minature  corns  appear  on  the  palms.  Usually  there  are  about  a  dozen  on 
each  hand ;  there  may  be  only  two  or  three,  or  they  may  be  much  more 
plentiful.  They  cause  neither  itching  nor  pain,  but  are  in  rare  instances 
tender  under  ])ressure.  Tiiey  I'un  an  indolent  course,  and  disap|)ear  chiefly 
by  scaling.  They  are  composed  of  dense  masses  of  epidermal  scales, 
which  can  be  dug  out  with  a  knife.     Usually  they  are  of  little  importance. 

The  well-marked  -scaling  syphilides  of  these  parts  may  appear  as  early 
as  the  third  month  of  syphilis,  at  the  time  of  a  relapsing  eruption,  or  even 
at  a  much  later  period.  They  usually  begin  during  or  at  the  decline  of 
an  eruption  of  the  flat  papular  syphilide,  but  they  may  be  developed  in- 
dependently. In  the  hollow  of  the  palm  or  sole  a  few  flat  papules  of  a 
diameter  of  one  or  two  lines  appear.  At  first  the  elementary  lesion  can 
be  distinctly  recognized,  being  elevated,  sharply  outlined,  and  of  a  deep  red 
color.  If  treatment  is  neglected  they  soon  become  flattened,  and  lose 
their  color  and  well  defined  margins.  Meanwhile  other  papules  may  be 
formed  on  the  borders  of  the  palms,  which  likewise  soon  lose  their  char- 
acteristics. They  all  increase  in  size,  and  may  form  irregular  patches  by 
fusion.  In  severe  cases  the  entire  palm  and  the  fingers  may  be  invaded, 
when  we  find  either  a  number  of  small  patches  or  a  large  one  in  the  hol- 
low of  the  hand,  with  smaller  ones  around  it. 

These  patches  constitute  the  true  scaling  syphilide  of  these  parts,  and 
are  called  by  most  authors  "sypliilitic  psoriasis  of  the  {)alms  and  soles." 
By  careful  examination  we  find  general  thickening  of  the  epidermal  layer, 
with  much  scaling  and  redness  of  the  surface.  The  papules  are  frequently 
seated  in  the  furrows  of  the  hand,  which,  in  severe  cases,  may  be  con- 
34 


530  SYPHILIDES. 

verted  into  superficial  fissures  or  "  rhagades."  When  thus  developed, 
this  sypliilide  may  persist  for  months  or  years,  causing  annoyance  by  the 
desquamation  and  the  feeling  of  stiftiiess  produced,  and  giving  rise  to  pain 
when  fissures  are  formed. 

In  some  cases  the  disease  creeps  slowly  up  the  fingers  until  it  reaches 
the  nails,  which  then  become  tliickened  and  brittle.  In  some  instances 
one  or  more  well  marked  rings  of  papules  occur  on  these  localities.  If  not 
cured,  these  soon  coalesce  and  form  a  patch,  which  runs  the  usual  course. 
As  a  rule,  the  afi^'ection  spreads  by  the  formation  of  new  distinct  papules 
at  the  border  of  the  original  patch.  Exceptionally  when  a  large  patch  has 
formed  in  the  hollow  of  the  hand,  the  disease  extends  by  a  crescentic 
margin,  a  line  or  more  in  width,  which  is  distinctly  elevated,  and,  as  it 
invades  healthy  tissues,  tlie  parts  left  are  scaly  and  subacutely  inflamed. 
In  this  way  the  whole  palm  or  sole,  with  the  corresponding  surfaces  of  the 
fingei's  or  toes,  may  be  involved.  Sometimes  the  lesion  progresses  in  this 
crescentic  manner  up  the  inner  side  of  the  foot  towards  the  ankle,  and 
around  the  radial  or  ulnar  borders  of  the  hand,  generally  not  invading  the 
dorsum  and  not  passing  the  line  of  the  wrist.  The  lateral  surfaces  of  the 
fingers  may  likewise  be  affected. 

Several  years  are  occupied  by  this  process,  and  as  a  result  we  sometimes 
find  general  cornification  of  the  dense  parts  of  the  epidermis  with  thicken- 
ing of  the  thinner  parts.  The  dense,  hard  stratum  of  epidermis  covering 
the  sole,  and  rather  less  frequently  the  palm,  often  becomes  perforated 
with  minute  holes,  while  from  it  may  be  dug  hard  masses  of  epidermis 
having  a  chalky  appearance.  This  affection  is  called  by  some  "  Syphilis 
cutanea  cornea.''''  All  of  these  forms  of  epidermal  thickening  are  very 
often  wholly  uninfluenced  by  internal  treatment,  and  always  require  vigor- 
ous local  measures. 

To  the  question  whether  syphilis  produces  genuine  scaling  eruptions 
we  must  answer  that,  while  they  may  be  scaly  and  no  infiltration  of  granu- 
lation cells  can  be  found  in  their  later  stages,  all  syphilitic  scaling  erup- 
tions begin  as  a  true  papular  sypliilide.  Owing  to  the  fact  that  the  infeg- 
ument  of  the  palms  and  soles  is  so  firmly  bound  down  and  is  subject  to 
such  constant  compression  and  attrition,  and  also  to  the  fact  that  the  cell- 
infiltration  in  these  regions  is  not  limited  to  the  vicinity  of  follicles,  the 
lesion  becomes  spread  out  into  extensive  patches.  Probably  the  specific 
feature  of  the  process  is  the  deposit  of  cells,  which  are  subsequently  ab- 
sorbed ;  resulting  from  this  is  a  low  grade  of  inflammation  and  a  chronic 
epidermal  cell-increase.  Therefore,  while  the  papular  lesion  is  character- 
istic of  syphilis,  the  scaling  which  follows  is  in  all  essentials  similar  to  that 
of  psoriasis.  Tlie  application  of  tlie  term  psoriasis  is,  however,  objection- 
able. ^Moreover,  the  result  of  treatment  shows  that  the  papular  affection  is 
influenced  by  mercury,  while  the  scaling  condition  is  unafl^ected. 

The  diagnosis  of  tlie  early  papular  syph Hides  of  the  palms  and  soles  is 
generally  easy,  since  neither  eczema  nor  j)Soriasis  produces  similar  appear- 
ances. In  their  early  stage  the  color  and  situation  of  the  patches  indicate 
their  nature,  while  tlie   history  of  the  case  and  the  coexistence  of  other 


THE    PUSTULAR    SYPHILIDES.  531 

svpliilitic  lesions  furnish  additional  evidence.  When  the  patches  are  dif- 
fuse, their  resemblance  to  psoriasis  is  almost  perfect.  The  latter,  however, 
is  often  more  scaly,  is  usually  more  scattered,  and  is  scaly  from  the  first, 
or  begins  as  rosy  red  patches  and  scaling  spots. 

It  is  always  important  to  get  the  patient's  idea  of  the  manner  in  which 
the  affection  began.  In  cases  of  psoriasis  similar  conditions  have  been 
observed  elsewhere  on  the  body.  Psoriasis  usually  begins  in  early  life,  the 
syphilitic  affection  generally  occurs  after  puberty.  It  is  very  rare  indeed 
for  psoriasis  to  appear  exclusively  in  these  localities ;  when  seen  here  it 
may  usually  be  found  elsewhere,  especially  on  the  elbows  and  knees. 
Some  authors  mention  as  a  point  of  distinction  that  the  scales  of  psoriasis 
are  silvery,  vvliile  tiiose  of  the  papular  syphilide  are  dull  and  dry.  We 
have  seen  the  scales  of  the  specific  affection  silvery,  resembling  asbestos. 
In  many  old  chronic  cases  the  diagnosis  cannot  be  made  from  the  study 
of  the  eruption  itself,  but  only  after  a  careful  consideration  of  its  history 
and  of  the  case  in  general.  Certain  chronic  palmar  eczemas  resemble  the 
scaling  sypjiilide.  Usually  there  is  more  thickening  in  the  former,  and 
there  is  always  much  itching.  It  is  more  diffuse  than  the  syphilitic  affec- 
tion, and  has  a  tendency  to  invade  contiguous  parts. 

The  Pustular  Syphilides. 

These  syphilides  constitute  an  important  group  of  eruptions,  which, 
though  less  common  than  the  erythematous  and  papular  forms,  may  appear 
at  the  earliest  stage  of  syphilis,  at  any  time  in  its  secondary  period  or  even 
late  in  its  tertiary  period.  They  vary  in  severity  from  a  mild  and  ephe- 
meral eruption  to  one  of  the  gravest  character.  The  size  of  the  pustules 
varies  from  that  of  a  pin's  head  to  that  of  a  ten-cent-piece ;  they  may  be 
acuminate,  globular,  or  flat;  they  are  generally  round,  but  sometimes  oval ; 
and  they  are  surrounded  by  a  dull  coppery-red  areola.  vSome  have  a  well- 
marked  papular  base,  the  pustule  being  a  minor  part  of  the  lesion  ;  beneath 
all  of  them  there  is  more  or  less  infiltration.  They  may  begin  as  papules 
or  as  distinct  pustules.  They  vary  greatly  in  number,  sometimes  covering 
the  entire  body,  or,  on  the  contrary,  being  limited  to  special  regions. 
They  show  a  marked  tendency  to  appear  on  localities  rich  in  hair  and 
sebaceous  follicles,  while  certain  ones  are  prone  to  be  developed  in  particular 
regions.  The  pustules  may  be  either  scattered  or  in  groups,  and  are  al- 
most always  symmetrically  placed.  Relapses  of  this  syphilide  are  common  ; 
the  earlier  the  eruption  the  more  rapid  is  its  invasion  and  the  more  nume- 
rous are  its  lesions,  while  later  eru})tions  appear  slowly,  in  limited  numbers 
and  with  a  marked  tendency  to  localization. 

Some  pustules  become  encrusted  more  quickly  than  others ;  as  a  rule 
the  secretion  of  the  large  ones  dries  sooner  than  that  of  the  small.  In  all 
cases  the  size  and  form  of  the  crust  correspond  to  those  of  the  pustule. 
The  crusts  of  the  small  pustules  have  a  greenish-brown  color,  those  of 
larger  and  later  ones  a  greenish-black  color,  similar  to  that  of  an  oyster- 
siiell.      They  are   usually  of  firm  consistence,  and  somewhat   adherent. 


532  SYPHILIDES. 

Their  surface  is  rough  and  sometimes  distinctly  himinated,  and  maybe  flat 
or  conical.  Their  shape  may  he  round,  oval  or  like  a  horse-shoe.  Under 
snfiall  crusts  tliere  is  usually  little,  if  any,  ulceration,  and  their  removal 
exposes  a  well-marked  papule  ;  under  larger  ones  is  an  ulcerating  surface, 
more  or  less  deep,  of  a  grayish-red  color,  covered  with  a  quantity  of  thick 
brownish-yellow  pus. 

The  earlier  eruptions,  being  jjapulo-pustular,  usually  cause  no  destruction 
of  the  skin,  while  the  late  ones,  being  extensive,  deep  and  localized,  leave 
cicatrices,  wliich  remain  pigmented  for  a  long  time,  but  finally  become 
shining  white. 

Ti)()ugh  the  visible  changes  are  pustulo-crustaceous,  the  base  of  all  of 
tliese  lesions  consists  of  an  infiltration  of  small  round  granulation  cells 
similar  to  that  of  pai)ules.  In  the  early  history  of  these  lesions  molecular 
decay  and  pus  formation  seem  to  be  in  proportion  to  the  cell-infiltration, 
the  destruction  of  tissue  very  often  being  limited  to  the  death  of  the  new 
cells,  since  perceptible  change  in  the  skin  itself  seldom  exists.  In  other 
cases  the  derma  melts  away  with  the  infiltration,  leaving  nothing  of  the 
original  framework. 

The  Acne-form  Syphilide. 

This  syphilide  is  thus  called  because,  like  acne  vulgaris,  it  attacks  the 
liair  and  sebaceous  follicles,  and  because  it  is  a  papulo-pustular  lesion.  It 
consists  of  conical  or  slightly  rounded  pustules  varying  in  diameter  and 
elevation  from  one-third  of  a  line  to  a  line.  Sometimes  the  pustules  are 
as  small  as  a  pinhead.  The  pustules  may  form  the  whole  eruption,  or  they 
may  be  mingled  with  miliary  j)apules  or  the  erythematous  syphilide. 

When  appearing  at  the  beginning  of  the  secondary  stage  as  a  general 
eruption,  they  are  usually  accompanied  by  fever,  which  sometimes  reaches 
the  highest  point  observed  in  syphilis,  and  by  other  symptoms  peculiar  to 
that  stage.  The  mode  of  invasion  may  be  rapid  or  subacute.  In  the 
former  case  the  small  red  spots  rapidly  become  papular  and  then  pustular, 
the  lesion  reaching  its  full  development  within  twenty-four  or  forty-eight 
hours.  In  such  cases  the  pustules  are  generally  numerous  and  scattered 
over  the  whole  body.  In  the  subacute  form  they  appear  slowly,  and  for 
several  days  may  look  like  papules,  on  the  apices  of  which  a  small  quan- 
tity of  pus  slowly  forms.  The  lesions  are  less  numerous,  more  localized, 
and  more  likely  to  be  grouped  than  in  the  acute  form.  The  fever  in  the 
latter  mode  of  invasion  often  rises  abruptly,  and  continues  at  a  high  grade 
for  several  days,  when  it  may  fall  abruptly  or  slowly  to  a  point  between 
99°  and  101°.  In  the  subacute  form  it  usually  rises  slowly  to  100°  or 
101°,  and  may  remain  at  or  about  that  elevation  for  several  weeks. 

Tlie  color  of  the  base  of  the  pustules  is  at  first  bright  red,  but,  as  in  tlie 
case  of  miliary  papules,  it  soon  becomes  dull  brownish-red.  This  change 
first  occurs  on  the  legs  and  face,  and  upon  the  former  the  pustules  are 
sometimes  accompanied  by  hemorrhagic  efi'usion.  The  ajjex  of  the  pus- 
tules is  at  first  yellow,  but  is  soon  transformed  into  a  greenish-brown. 


THE    PUSTULAR    SYPHILIDES.  533 

slightly  adherent  crust.  In  many  cases,  particularly  of"  small  pustules,  the 
purulent  apex  is  thrown  otf,  leaving  a  papule,  which  may  be  surrounded  by 
the  detached  rim  or  collarette  already  described  as  a  feature  of  the  papular 
syphilides.  Subsequently  the  papule  is  absorbed,  leaving  a  small  pig- 
mented spot.  In  cases  not  treated,  and  especially  in  badly  nourished 
subjects,  the  pustules  become  small  ulcers.  Their  base  extends,  being 
very  hypera^mic,  and  the  crust  enlarges  with  the  extending  ulceration.  It 
may  thus  happen  that  some  of  the  pustules  run  together,  although  there  is 
no  general  tendency  to  fusion  ;  and  they  may  be  distributed  in  the  form  of 
complete  or  partial  rings. 

This  eruption  generally  begins  about  the  face,  scalp,  back  of  neck,  and 
shoulders,  and  may  thence  invade  the  trunk  and  extremities,  being  more 
copious  on  the  scapular,  sternal  and  gluteal  regions,  and  on  the  outer  as- 
pects of  the  limbs.  We  frequently  find  syphilitic  papules  or  erythematous 
patches  on  the  inner  surface  of  the  arms  and  legs  and  on  the  anterior  as- 
pect of  the  trunk.  When  the  pustules  are  scattered  over  the  entire  body, 
they  may  be  closely  ci'owded  together  or  separated  by  marked  intervals. 
The  first  eruptions  are  always  more  copious  than  rela[)ses,  in  which  the 
pustules  appear  possibly  grouped  in  patches  or  in  a  ringed  form  about  the 
face,  scalp,  or  shoulders,  usually  liaving  been  preceded  by  an  erythematous 
or  papular  syphilide. 

This  eruption,  which  generally  appears  from  the  third  to  the  sixth 
month  of  the  secondary  period,  may  run  a  chronic  course,  occupying 
several  months  in  the  development  and  complete  disappearance  of  the 
lesions.  Having  run  its  course  it  usually  does  not  relapse  in  its  original 
form,  but  in  the  form  -of  larger  and  deeper  pustules  or  tubercles. 

Commonly  the  skin  is  not  destroyed,  the  pustules  merely  leaving  small 
brown  spots  which  disappear  in  a  few  months.  The  hair  of  the  scalp 
falls  from  the  affected  follicles,  but  is  usually  replaced;  exceptionally  the 
follicle  is  destroyed,  and  a  minute  cicatrix  results. 

llie  prognosis  of  this  syphilide  is  not  so  good  as  that  of  other  earlier 
forms.  The  eruption  itself  is  troublesome,  and  the  general  health  is  rather 
more  frequently  impaired  after  this  rash  than  after  others. 

The  concomitant  symptoms  vary  with  the  date  at  which  tlie  eruption 
appears.  If  it  is  the  first  rash  it  is  of  course  accompanied  by  symptoms 
and  lesions  peculiar  to  the  period  of  invasion;  at  a  later  period  it  may  co- 
exist with  alopecia,  onychia,  mucous  patches,  iritis,  neuralgias,  nervous 
symptoms,  and  perhaps  lesions  of  the  bones  and  testes. 

Diagnosis The  history  of  the  case,  the  usual  presence  of  other  lesions, 

and  the  appearance  of  a  generally  distributed  pustular  syphilide  preclude 
the  possibility  of  mistake.  Acne  vulgaris  resembles  it  in  certain  particu- 
lars. Acne,  however,  generally  begins  about  puberty,  and  is  confined  to 
tlie  fjice  and  back  and  rarely  attacks  the  hair  of  the  scalp.  It  is  never 
attended  by  systemic  reaction.  Moreover,  it  presents  papules,  pustules 
and  comedones,  which  have  no  uniformity  of  size:  some  are  indeed  minia- 
ture furuncles,  and  all  have  at  some  time  a  more  or  less  hypera^mic  areola. 
Tlie  pustules  retain   their  character  indefinitely,  and,  on  pressure,  pus  ex- 


534  SYPHILIDES. 

luU's  from  a  cavity,  whereas  in  the  sypliilitic  lesion,  the  pus  surmounts  a 
])ii|)ular  base.  Acne  attacks  exchisively  the  up[)er  parts  of  the  body  ; 
syphilis  may  be  general. 

In  its  papular  stage  the  pustular  syphilide,  when  grouped,  may  resemble 
lichen,  the  distinguishing  points  of  which  have  been  given  in  describing 
the  miliary  pai)ules. 

Some  French  writers  have  called  this  eruption  a  "  vesicular  syphilide," 
since  the  purulent  contents  of  the  pustule  are  occasionally  so  thin  as  to 
resemble  serum.  About  tlie  face,  and  especially  the  chin,  a  few  well- 
marked  vesicles  may,  in  rare  cases,  be  seen.  They  are  very  minute,  may 
be  grouped  in  a  ringed  form,  and  they  either  become  pustular  or  they  flat- 
ten, scale,  and  become  pigment  spots.  Usually  pus  is  present  from  the 
first. 

In  exceptional  cases  pustules  are  found  on  the  sides  of  the  thorax  along 
the  line  of  the  ribs,  presenting  some  resemblance  to  herpes  zoster.  They 
are  always  symmeti"ica],  whereas  herpes  is  rarely  so.  The  syphilitic  lesions 
are  not  preceded  nor  followed  by  pain  as  is  the  case  in  herpes.  In  the 
latter  atFection,  moreover,  the  lesions  are  generally  limited  to  the  intercos- 
tal sj)aces  and,  if  found  elsewhere,  follow  the  course  of  some  nerve,  where- 
as in  syphilis  the  localities  are  quite  deflnite  and  other  specific  lesions  may 
coexist. 

Tlie  Variola-form  Syphilide. 

This  eruption  is  much  less  common  than  the  acne-form  variety,  and  is 
interesting  chiefly  in  its  resemblance  to  varicella  and  variola.  It  is  rarely 
the  first  eruption  of  syphilis,  but  appears  after  any  of  the  early  rashes. 

It  consists  of  round,  superficial  pustules,  the  epidermis  covering  the  pus 
being  rather  thin.  It  begins  in  the  form  of  red  spots,  which  within  a  day 
or  two  become  pustules  with  a  diameter  and  an  elevation  of  one  or  two 
lines.  These  pustules  are  surrounded  by  a  limited,  deep-red  areola,  and 
there  is  evidently  not  very  much  thickening  at  their  bases.  When  f«lly 
developed  they  flatten  slightly  at  the  centre,  some  presenting  marked  um- 
bilication.  The  epithelial  cover  of  the  pustules  slowly  shrinks,  becomes 
darker,  and  finally,  in  a  few  weeks  or  sooner,  deep,  greenish-brown  crusts, 
about  half  a  line  in  thickness,  are  formed,  which  adhere  somewhat  closely 
to  a  slightly  exulcerated  base.  In  general  the  pustules  run  an  indolent 
course  and  do  )iot  increase  much  in  size,  but  in  aggravated  cases  they 
become  very  large  and  may  run  together.  They  may  be  disseminated 
over  the  body  or  grouped  in  particular  regions,  and  they  som(!times  form 
circles  and  parts  of  circles. 

These  pustules  have  no  tendency  to  a  follicular  origin,  but  are  found  on 
parts  where  the  skin  is  soft  and  delicate,  frecpieutly  like  other  syphilides, 
upon  the  forehead  and  at  the  line  of  junction  of  skin  with  mucous  mem- 
brane. They  are  generally  sparse  on  the  outer  aspect  of  the  extremities, 
more  numerous  on  the  anterior  of  the  trunk,  and  often  abundant  near  the 
genitals  and  in  the  inguinal  region.     In  rare  cases  they  are  found  on  the 


THE    PUSTULAR    SYPHILIDES.  535 

palms,  and  still  more  seldom  on  the  soles  :  we  have  seen  but  one  instance  of 
the  latter,  and  very  few  such  cases  have  been  reported. 

On  account  of  the  large  size  of  the  pustules  this  syphilide  has  been 
called  by  some  French  writers  '^ pemphi'ffus  syphiliticus,"  and,  owino-  to 
its  occasional  development  upon  the  palms,  it  has  been  claimed  that  pem- 
phigus may  occur  here  in  acquired  as  well  as  in  hereditary  syphilis.  The 
large  pustules  which  may  form  in  these  regions  in  acquired  syphilis  are 
not,  however,  pemphigoid  bullje.  The  thickness  and  firm  attachment  of 
the  skin  of  these  parts  prevent  elevation  of  the  epidermis  to  a  great  deo-ree ; 
hence  the  pustules  spread  out  and  run  together,  thus  coming  to  resemble 
bullae.  While  admitting  the  rare  occui'rence  of  pemphigus  in  acquired 
syphilis,  we  do  not  believe  that  it  is  developed  upon  the  palms  and  soles. 

The  mode  of  invasion  of  this  eruption  is  generally  rather  slow,  and  is 
seldom  accompanied  by  very  pronounced  febrile  movement.  It  beofjns 
about  the  face  and  thence  spreads  slowly  over  the  body  in  the  course  of 
one  or  two  weeks.  The  crusts,  which  form  when  the  pustules  reach  their 
height,  fall  oiF,  leaving  pigmented  spots.  Sometimes  new  crops  rapidly 
succeed  old  ones,  so  that  an  eruption  may  last  several  months.  The  erup- 
tion is  greatly  influenced  by  treatment;  although  its  full  arrest  is  difficult, 
future  outbursts  may  be  prevented. 

We  cannot  say  from  our  own  experience  how  such  an  eruption,  if  left  to 
itself,  might  progress,  but  it  would  probably  ulcerate  deeply  and  induce  a 
condition  of  marasmus.  Under  such  circumstances,  when  the  eruption 
seems  to  assume  a  malignant  type  and  is  accompanied  by  cachexia,  we 
have  an  illustration  of  a  somewiiat  rare  form  of  syphilis  called  by  the 
French  ^^  precocious  malignant  syphilis"  (syphilis  maligne  precoce)  or 
^'■galloping  syphilis"  (syphilis  gallopante).  Any  form  of  pustular  syphil- 
ide may  assume  these  characters. 

A  very  limited  eruption  of  this  syphilide  sometimes  occurs  on  the  face 
or  body,  or  symmetrically  on  the  arms.  Such  a  rash  runs  a  slow  course, 
usually  without  much  fever,  and  generally  occurs  in.  cases  where  treatment 
has  been  stopped  too  early. 

This  eruption  rarely  appears  earlier  than  tlie  third  month,  and  may  be 
seen  as  late  as  the  second  year  of  syphilis.  AVith  it  may  be  found  lesions 
peculiar  to  this  period,  and  frequently  a  sparse  papular  eruption,  mucous 
patches,  or  condylomata  lata. 

The  diagnosis  of  this  syphilide  is  generally  easy.  Prodromal  symptoms 
observed  in  smallpox  and  varicelhi,  such  as  backache  and  eruptive  fever, 
are  noticeably  absent,  and  there  is  much  less  general  disturbance.  In  the 
acute  eruptions  there  is  great  lieat  and  tension  of  the  skin,  and  at  the  out- 
set small  shot-like  papules  may  be  felt,  which  rapidly  pustulate.  More  or 
less  diffuse  patches  of  hypenemia,  accompanied  by  sensations  of  itching 
and  burning  of  the  skin,  are  present.  Variola  progresses  so  rapidly  that 
its  cliaracter  is  perfectly  clear  after  the  second  day.  The  slow  develop- 
ment of  tlie  sypliilitic  eruj)tion,  and  the  absence  of  subjective  symptoms 
are  distinctive  points  in  the  diagnosis. 


536  SYPHILIDES. 

The  Impeti (jo-form  Syphilide. 

This  syphilide,  like  the  precetling,  is  a  piistulo-crustaceous  eruption, 
and  attacks  the  more  superficial  layers  of  the  skin,  differing  from  it,  how- 
ever, in  the  fact  that  the  lesions  are  not  so  distinctly  circumscribed,  but 
have  a  tendency  to  involve  a  much  greater  surface  and  often  to  assume  a 
serpiginous  character. 

The  resemblance  of  this  eruption  to  simple  imjietigo  is  in  the  grou[)ing 
of  the  pustules,  in  their  fusion,  and  chiefly  in  the  somewhat  similar  ap})ear- 
ance  of  the  crusts.  The  pustules  of  the  specific  eruption  are  usually  much 
larger  and  flatter  than  those  of  the  simple  form,  and  their  resemblance  is 
hardly  so  close  as  to  warrant  the  term  impetigo-form  ap[)lied  to  them. 
They  dry  so  quickly  into  crusts  that  the  pustular  stage  is  soon  lost. 

This  syphilide  almost  never  occurs  as  the  first  exanthem,  but  rather  dur- 
ing a  late  relapse,  its  earliest  ap[)earance  being  at  the  decline  of  the  initial 
rash,  and  its  usual  time  of  evolution  being  about  the  middle  or  latter  part 
of  the  first  year  of  syphilis.  In  cases  not  treated,  it  may  occur  during 
the  second  or  even  the  third  year.  Most  of  the  pustules  have  a  peri-fol- 
licular  origin,  and  are  found  on  hairy  parts,  rarely  on  the  hands  and  feet. 
When  this  syphilide  occurs  early,  the  pustules  are  rather  discretely  dis- 
tributed over  the  whole  body  ;  when  it  appears  later,  they  are  distinctly 
localized  and  grouped,  the  eruption  in  the  latter  csise  being  ii'A\\it(\  impetigo 
syphilitica  conferta. 

The  pustules  begin  as  circumscribed  red  spots  which  rapidly  become 
elevated  by  yellow  pus  seated  beneath  the  epidermis.  These  spots,  few  of 
which  are  papular,  are  sometimes  small  and  round,  and  again  are  very 
large  and  irregularly  oval.  After  the  effusion  of  pus,  each  patch  becomes 
covered  by  a  dark-brown  adherent  crust.  The  crusts  of  several  pustules 
may  run  together,  their  mode  of  formation  being  indicated  by  incomplete 
lines  of  separation.  Their  surfaces  are  usually  flat,  their  edges  rounded 
and  in  relation  with  the  margin  of  the  ulcer,  and  they  are  surrounded  by 
a  narrow  dull-red  areola. 

Upon  the  face,  at  the  margin  of  the  hairy  scalp,  in  the  scalp  itself, 
about  the  alae  nasi  and  commissures  of  the  li})s,  upon  the  chin  and  in  the 
beard,  these  crustaceous  pustules  run  together  and  form  patches,  usually 
not  more  than  two  inches  in  diameter.  In  the  hairy  parts  the  outline  of 
the  incrustations  is  generally  not  at  all  regular.  Only  in  late  eruptions 
do  the  pustules  unite  and  form  large  patches.  On  the  trunk,  a  few 
may  be  seen  over  the  sternum  and  in  the  hypogastric,  inguinal,  and 
gluteal  regions.  On  the  anterior  aspect  of  the  forearms,  and  more  rarely 
of  the  thighs,  some  may  also  be  found,  and  here  they  are  likely  to  be 
grouped  and  to  increase  rapidly  in  size,  a  pustule  sometimes  reaching  a 
diameter  of  an  inch  or  more  within  two  weeks.  The  pustules  usually  re- 
tain their  circular  form  as  they  increase  in  size,  but  sometimes  they  become 
kidney-shaped  ;  this  peculiarity  is  noticed  rarely  on  the  face,  but  more  com- 
luonly  on  the  forearm. 

In   some   untreated   and  broken-down  cases,  these   pustulo-crustaceous 


THE    PUSTULAR    SYPHILIDES.  53Y 

lesions  take  a  serpiginous  course,  invading  the  superficial  layers  of  the 
derma,  generally  of  the  upper  extremities.  They  progress  by  a  ring  of 
ulceration,  covered  by  a  crust  and  inclosing  an  area  of  skin  already  healed. 
This  ring  of  ulceration  is  prone  to  extend  in  a  circular  form  on  the  face 
and  in  an  oval  form  on  the  arms.  When  the  patch  is  a  few  inches  in  dia- 
meter, tlie  aspect  of  the  original  lesion  is  wholly  lost.  We  then  find  a  dis- 
tinctly raised  ring,  one  to  three  lines  in  breadth,  of  a  yellowish-brown  or 
black  color,  which  incloses  a  round  spot  of  slightly  hyperajmic  skin.  The 
ring  gradually  extends  until  the  whole  forearm  and  part  of  the  arm,  the 
greater  part  of  the  face,  or  the  entire  sternal  region  may  be  invaded. 
Even  in  tlie  worst  cases,  surprisingly  little  alteration  of  the  skin  follows 
tiiis  process,  and,  in  many,  no  cliange  whatever  is  apparent. 

Besides  this  superficial  form  of  the  serpiginous  sypliilide  there  is  a 
similar  lesion  which  attacks  the  tissues  more  deeply  and  induces  destruc- 
tion and  cicatrization  of  the  skin.  This  latter  eruption  we  shall  call  the 
serpiginous  tubercular  syphilide.  The  superficial  serpiginous  syphilide 
may  also  begin  as  a  variola-form  pustule,  and  may  persist  many  months  or 
even  years.  While  it  usually  attacks  large  areas  superficially,  it  may  also 
attack  deeper  portions  of  the  skin.  In  the  latter  case,  the  areolae  of  tlie 
pustular  ulcers  become  thickened  and  more  red,  and  the  crust  becomes 
more  elevated  and  uneven.  Underneath  the  crust,  ulcei'ation  progresses, 
and,  instead  of  the  superficial  grayish-red  ulcer  usually  found,  there  is  a 
deep  and  sharply  cut  excavation,  with  a  red,  uneven  surface,  freely  covered 
with  secretion.  When  the  eruption  takes  this  course,  it  has  been  called 
sypliilitic  impetigo  rodens,  but  there  is  no  reason  to  consider  it  a  distinct 
eruption  ratiier  than  a  complication. 

The  ulcerations  vary  in  size ;  in  neglected  cases,  we  have  seen  them 
large  and  deep  on  the  scalp  and  in  the  beard,  and  more  superficial  upon 
the  forehead.  In  some  cases  the  alte  of  the  nose  may  be  lost.  The  de- 
struction of  tissue  is  generally  greater  about  the  face  and  head  tlian  else- 
where. Severe  cachexia  may  occur  coincidently  with  this  eruption  and 
other  serious  lesions  may  follow,  until  we  have  an  instance  of  malignant 
precocious  syphilis,  which  is  attended  by  much  suffering  and  may  even 
imperil  the  patient's  life.  Usually,  however,  now  that  syphilis  receives 
early  and  careful  treatment,  this  eruption  does  not  assume  these  destruc- 
tive features  ;  healing  takes  place  under  the  crusts,  whicli  are  then  tiirown 
off,  Ifiiving  a  smooth,  deep-red  surface,  which  may  be  slightly  scaly  and 
deeply  pigmented  for  several  months.  On  raising  the  crust  from  a  fully- 
developed  patch  on  the  arm,  we  usually  find  a  smooth,  reddisli-gray  ulcer 
without  undermined  edges;  on  the  face,  liowever,  tlie  surface  is  likely  to 
be  uneven  and  frerpuintly  covered  by  little  papillomatous  elevations,  over 
which  the  crusts  are  accurately  fitted.  This  warty  appearance,  which  is 
seldom  s<;en  on  hairy  parts,  is  the  result  of  an  increased  cell-infiltration 
around  follicular  openings.  These  uneven  surfaces  gradually  become  fiat 
and  lose  their  color. 

The  course  of  this  eruption  is  usually  very  chronic.  On  its  invasion 
the  pustules  may  be  very  numerous,  or  a  few  only  may  first  appear  on  the 


538  SYPIIILIDES. 

head.  Thus  for  long  periods  new  pustules  may  appear  as  old  ones  fade. 
In  other  cases,  a  general,  extensive  rash  may  run  its  full  course  in  a  com- 
paratively short  time. 

Coexistin"  lesions  are  those  peculiar  to  the  period  at  which  the  eruption 
appears.  Karely  being  an  early  eruption,  we  seldom  find  it  coincide  with 
the  erythematous  syphilide,  except  during  a  relapse  of  that  lesion.  It  is 
not  uncommonly  found,  in  a  sparse  and  limited  form,  with,  or  at  the  de- 
cline of,  one  of  the  papular  syphilides.  Condylomata  lata  are  frequently 
present  on  regions  which  this  eruption  attacks,  and  very  often  it  is  con- 
tinuous at  the  angle  of  the  mouth  with  a  mucous  patch  of  the  lip  or  cheek. 
Since  it  may  occur  at  any  time  in  the  secondary  or  tertiary  period  of 
syphilis,  any  of  the  intermediary  and  many  of  the  late  manifestations  of 
this  disease  may  be  present  with  it. 

This  syphilide  most  commonly  attacks  persons  in  a  debilitated  condi- 
tion, those  who  have  some  organic  disease,  or  who  have  neglected  early 
treatment.  The  prognosis  must,  therefore,  be  based  upon  the  patient's 
general  condition  as  well  as  upon  the  eruption  itself.  The  presence  of 
the  eruption,  however  slight,  is  an  indication  for  careful  and  continued 
treatment,  and  for  attention  to  the  patient's  nutrition  and  hygiene. 

This  syphilide  may  be  mistaken  for  impetigo  in  its  disseminated  and  in 
its  confluent  form.  The  lesions  of  impetigo  retain  their  pustular  character 
much  longer  than  do  those  of  sy})hilis.  Tliey  are  attended  by  heat  and 
itching  of  the  skin,  and  have  an  inflammatory  areola ;  they  are  much 
more  uniform  in  size  than  are  the  pustules  of  syphilis,  and  their  crusts  are 
of  a  greenish-yellow  color,  instead  of  the  greenish-black  of  syphilis.  The 
acuteness  of  invasion  in  the  case  of  large  patches  of  the  simple  eruption  is 
in  striking  contrast  with  the  slow,  painless,  and  indolent  character  of  the 
syphilide.  These  features,  considered  in  connection  with  the  history  of 
the  case,  make  the  diagnosis  clear. 

The  Ecthy ma-form  Syphilide. 

There  are  two  varieties  of  this  syphilide,  superficial  and  deep.  The 
superficial  is  the  earlier  eruption,  appeai'ing  at  any  time  during  the  first 
year  of  syphilis,  and  is  usually  composed  of  a  greater  number  of  pustules. 
The  latter  resemble  those  of  non-specific  ecthyma  in  having  a  solid,  ele- 
vated base,  surrounded  by  a  crust,  and  in  their  tendency  to  ulcerate.  ^  The 
deep  form  may  be  an  intermediary  lesion,  or  even  a  rather  late  one.  The 
pustules  of  the  superficial  form  vary  in  diameter  from  one  to  three  lines. 
They  begin  as  slight  red  elevations  of  the  skin,  which,  in  a  day  or  two, 
become  small,  conical  pustules.  The  pustules  gradually  increase  in  size, 
and  crusts  are  formed  by  desiccation  of  the  pus.  The  crusts  grow  in  pro- 
j)ortion  to  the  bases  of  the  pustules,  and  their  yellow  color  soon  becomes 
brown,  which  is  rendered  still  darker  by  particles  of  dirt,  and  sometimes 
by  admixture  of  a  little  blood.  When  fully  formed  their  color  is  yellowish- 
brown,  and  their  shape  round  or  conical.  As  the  pustules  increase  in 
size  the  crusts  become  flattened  and   even  depressed  at  the  centre.     The 


THE    PUSTULAR    SYPHILIDES.  539 

base  is  at  first  of  a  briglit  red  color,  wliicli  soon  becomes  a  dull  reddisli- 
brown,  and  it  is  surrounded  by  an  abruptly  limited  areola.  Beneath  the 
crust,  which  is  seldom  firmly  adherent,  is  an  ulceration,  involving  the 
superficial  layers  of  the  derma,  and  having  a  smooth  floor  covered  by  a 
grayish-red  film  of  molecular  detritus,  bathed  in  thick  pus.  After  com- 
mencing treatment,  and  with  improvement  in  the  general  health,  the  base 
becomes  less  dark,  and  contracts;  the  areola  fades;  the  crust  becomes 
hard,  dry,  and  very  adherent,  and,  if  removed,  a  smooth  red  surface  is 
seen,  sometimes  slightly  papillated.  This  surface  may  be  again  covered 
by  a  thin  crust  made  up  chiefly  of  epidermis,  which  in  turn  falls  off, 
leaving  a  smooth,  reddish-brown  patch,  or  a  slightly  elevated,  papular,  and 
scaly  surface.  Under  unfavorable  circumstances  the  areola  and  the  base 
are  redder  and  more  extended,  pus  is  secreted  in  greater  quantity,  the 
ulcer  increases  in  depth  and  extent,  in  extreme  cases  reaching  a  diameter 
of  one  or  two  inches,  and  perhaps  several  ulcere  may  unite.  In  such 
cases  the  syphilis  assumes  a  malignant  form,  and  there  is  much  systemic 
pi'ostration.  The  course  of  such  an  ulcer  is  similar  to  that  of  the  impetigo- 
form  syphilide  when  the  latter  becomes  serpiginous. 

The  superficial  ecthyma-form  syphilide  begins  by  the  development  of 
pustules  either  in  a  disseminated  or  an  aggregated  form,  about  the  scalp, 
particularly  at  its  junction  with  the  face  and  neck.  They  may  appear 
gradually  and  without  much  febrile  movement,  or  in  a  manner  quite  the 
reverse.  Soon  after,  other  portions  of  the  body,  such  as  the  anterior  sur- 
faces of  the  legs  and  forearms,  the  trunk,  and  the  inguinal  and  gluteal 
regions,  may  be  invaded.  In  some  cases  this  is  accomplished  in  a  week  or 
ten  days ;  in  otliers  small  crops  of  pustules  succeed  each  other  at  short 
intervals,  and  fully  a  month  may  be  occupied  in  the  complete  development 
of  the  eruption.  When  this  eruption  occurs  early,  and  especially  in  cases 
inefiiciently  treated,  the  lesions  are  apt  to  be  extensive  and  copious;  oc- 
curring later,  it  may  be  limited  to  one  region,  and  may  even  be  unsym- 
metrical.  The  pustules  may  be  isolated  or  grouped  in  patches,  or  in  the 
form  of  circles  or  parts  of  circles.     They  may  or  may  not  leave  cicatrices. 

The  deep  variety  of  the  ecthyma-form  syphilide  is  usually  a  rather  late 
lesion,  but  it  is  sometimes  precocious.  In  the  latter  case  it  may  be  very 
malignant,  and  it  is  then  the  expression  of  profound  syphilitic  cachexia, 
thus  constituting  another  instance  of  the  "  galloping  syphilis"  of  the 
French.  This  syphilide  begins  as  a  papulo-tubercle.  A  round  or  oval 
elevation  ap[)ears,  upon  which  a  quantity  of  yellow  ])us  soon  forms,  and 
this  becomes  thicker  and  dries  into  a  crust  of  a  brownish-black  color, 
owing  to  the  effusion  of  a  little  blood.  When  fully  formed,  we  find  an 
incrusted  papulo-tubercle,  with  a  diameter  of  one-quarter  to  one-half  of  an 
inch.  The  firm,  deeply-seated  base  has  a  dark  coppery-red  color,  and  is 
surrounded  by  an  areola  of  a  similar  hue.  The  crust  is  generally  rounded 
or  conical,  but  may  flatten  out  as  it  extends.  A  deep,  punched-out  ulcer, 
with  sharply-cut  edges,  and  a  smooth,  grayish-red  surface,  covered  with  a 
foul,  luist-colored  pus,  underlies  the  crust,  which  can  be  removed  with 
little  force.     In  some  cases  the  crust  fully  covers  the  ulcer,  in  others  it  is 


540  SYrHILlDES. 

smaller,  and  is  surrounded  by  a  ring  of  ulceration.  If  untreated,  the  ulcer 
continues  to  increase,  and  may  become  serpiginous,  invading  extensive 
surfaces.  Several  ulcers  may  merge  together.  Influenced  l)y  treatment, 
the  areola  fades,  the  base  contracts  and  becomes  slightly  wrinkled,  and  a 
granulating  surface  is  found  beneath  the  crust,  which  becomes  hard  and 
adherent.  In  some  cases,  as  a  result  of  stimulation,  a  layer  of  epidermis 
soon  covers  the  surface  of  the  ulcer,  but  often  profuse  granulations  spring 
up  and  may  even  rise  above  the  level  of  the  surrounding  skin.  After 
healing  of  the  ulcer,  there  remains  a  coppery-red  spot,  which  gradually 
fades,  and  finally, hmves  a  shining  white  cicatrix,  which  is  for  a  lor.g  time 
fringed  by  a  narrow  copper-colored  areola. 

This  eruption  is  generally  most  abundant  on  the  antero-exterior  surfaces 
of  the  legs  ;  often  a  few  pustules  may  form  on  the  corresponding  sui-faces 
of  the  arms,  or  about  the  face,  and  on  the  lower  portions  of  the  trunk.  It 
is  usually  developed  slowly,  appearing  in  crops  of  from  two  to  twelve  at 
intervals  of  one  or  several  weeks.  It  may  be  accompanied  by  cachexia, 
and  not  infrequently  by  fever  of  a  remittent  type.  The  course  of  the 
eruption  is  very  slow  and  insidious,  often  extending  over  many  months  or 
even  moi-e  than  a  year.  In  many  cases  there  is  no  true  cachexia,  but 
simply  extreme  prostration.  In  such  cases  the  ulcers  are  not  numerous, 
and  show  only  a  slight  tendency  to  spread. 

The  prognosis  of  this  syphilide  is  variable.  In  the  superficial  form  the 
eruption  often  gives  much  annoyance,  yet  it  may  disappear  without  leaving 
scars.  The  condition  of  the  system  is  always  below  par,  and  the  prognosis 
should  be  governed  in  great  measure  by  the  degree  of  improvement  under 
treatment.  In  most  cases  a  fsxvorable  result  may  be  expected  in  the  course 
of  a  few  months,  but  in  rare  cases  prolonged  cachexia  follows. 

The  prognosis  of  mild  and  limited  cases  of  the  deep  variety  is  usually 
good.  In  more  extensive  and  relapsing  cases,  the  outlook  is  less  favor- 
able ;  the  presence  of  the  eruption  indicates  a  depraved  condition  of  health, 
which  is  greatly  aggravated  by  the  irritation  and  drain  of  the  deep  ulcera- 
tions. A  few  months  of  proper  treatment  will,  however,  generally  effect 
a  cure. 

The  diagnosis  of  this  syphilide  is  almost  always  quite  easy,  although  it 
may  be  mistaken  for  ecthyma.  The  superficial  form  is  to  be  distinguished 
from  a  similar  ecthyma,  by  the  peculiar  course,  situation,  and  appearance 
of  the  syphilitic  pustules,  as  compared  with  the  more  inflammatory,  pruritic 
pustules  of  ecthyma,  which  are  more  uniform  in  size,  have  yellowish-brown 
crusts,  and  much  less  tendency  to  ulceration.  Moreover,  ectliyma  usually 
occurs  on  the  legs  of  broken-down  subjects,  and  is  an  eruption  of  papules 
and  pustules,  the  latter  forming  only  superficial  ulcers.  In  some  cases  of 
phtheiriasis,  in  uncleanly  and  unhealthy  persons,  pustulo-crustaceous  ulcers, 
somewhat  resembling  those  of  syphilis,  are  seen,  but  with  care  a  diagnosis 
can  always  be  made.  The  discovery  of  the  pediculus  vestimentorum,  the 
])resence  of  minute  blood-crusts  caused  by  the  bite  of  the  insect,  and  very 
often  scratch-marks,  and  a  general  papular  and  pruritic  condition,  estab- 
lish the  diagnosis  of  phtheiriasis. 


THE    PDSTULAR    SYPHILIDES.  541 

The  deep  ecthyma-form  syphilide  might  perhaps  be  mistaken  for 
ecthyma  cachectica  livida,  since  the  latter  occurs  in  much  debilitated 
subjects.  The  histories  of*  the  cases,  and  a  comparison  of  the  lesions, 
render  the  distinction  clear.  The  lesions  of  syphilis  are  less  inflammatory 
than  those  of  the  non-specific  eruption  ;  they  involve  much  less  of  the  sur- 
face, but  extend  much  deeper,  and  they  secrete  much  less  pus.  Moreover, 
the  areola  of  the  simple  lesion  is  either  bright  red  or  deep  purple,  and  is 
much  more  extensive  than  that  of  the  syphilitic  pustule. 

Rupia. 

This  name,  derived  from  the  Greek  ^vrto^,  dirt,  is  applied  to  an  eruption 
composed  of  ulcers  surmounted  by  laminated  crusts.  It  appears  some- 
times precociously  during  the  first  year  of  syphilis,  but  it  really  belongs 
among  the  late  lesions.  It  usually  shows  intense  syphilitic  infection,  and 
is  often  accompanied  by  fever.  It  has  never  been  seen  in  hereditary 
syphilis.  Although  a  pustulo-crustaceous  eruption,  it  partakes  of  the 
nature  of  tertiary  lesions,  in  the  deep-seated  infiltration  always  present 
beneath  the  crusts. 

Rupia  may  be  divided  into  two  varieties  :  one,  in  which  the  crusts  are 
small,  numerous,  and  quite  generally  scattered  ;  another,  in  which  they 
are  large,  less  numerous,  and  more  localized.  All  of  the  lesions  of  rupia 
begin  as  a  red  spot,  which  soon  becomes  a  flat  pustule,  which  dries  into  a 
greenish-brown  crust.  Subsequent  changes  are  very  slow  and  of  great 
interest.  The  initial  crust  is  usually  small,  and  underneath  it  is  a  superfi- 
cially ulcerated,  infiltrated  surface.  The  infiltration  and  ulceration  extend 
somewhat  beyond  the  original  crust,  and  another  layer  of  crust  is  formed 
beneath  it  by  the  secretion  from  the  ulcerated  surface.  Thus  several  dis- 
tinct but  adherent  laminations  are  formed  as  the  ulcer  increases  in  size, 
each  succeeding  one  being  larger  than  its  predecessor.  This  result  is 
mainly  due  to  the  fact  that  the  pus  is  quite  thick,  and  that  it  is  secreted 
slowly  and  dries  very  quickly.  The  process  may  continue  until  the  crusts 
reach  a  diameter  of  half  an  inch  or  even  two  inches.  In  rare  cases  they 
have  been  seen  with  a  diameter  of  fully  six  inches.  "When  completed, 
the  rupial  crust  is  conical,  distinctly  laminated,  of  a  brownish-black  color 
tinged  with  green,  similar  to  a  dirty  oyster  shell.  The  crust  itself  is 
hard,  firm,  and  adherent,  although  its  layers  are  often  perfectly  distinct. 
Underneath  it  we  find  an  unhealthy,  grayish-red,  ulcerated  surface,  bathed 
In  thick,  ichorous  pus,  and  surrounded  by  a  slightly  undermined  margin. 
The  de[)th  of  this  ulcer  is  rarely  so  great  as  that  of  the  severe  echthyma- 
iorm  syphilide.  It  generally  involves  about  one-half  the  thickness  of  the 
derma.  Around  each  ulcer  is  an  areola  of  a  coppery-red  color,  which 
merges  into  healthy  tissue.  The  growth  of  these  encrusted  ulcers  is  quite 
slow  and  often  intermittent. 

The  small  rupial  eruption  begins  either  about  the  face  or  on  the  inner 
and  outer  surface  of  the  forearms.  It  may  then  invade  the  trunk  and 
lower  extremities.     The  crusts  vary  in  diameter  from  half  an  inch  to  an 


542  SYPHILIDES. 

inch.  Lamination  is  first  visible  when  their  diameter  is  about  one-quarter 
of  an  inch.  Their  number  varies;  sometimes  upon  the  face  only  a  small 
portion  of  healthy  skin  is  left  intact.  Upon  the  face  and  forearms  their 
heit'ht  is  often  greater  than  their  breadth.  They  are  more  common  on 
the  forehead  and  near  the  nose  and  mouth  than  on  other  parts  of  the  face. 
In  some  cases  only  one  region  is  invaded,  as  the  face  or  the  forearms,  but 
the  eruption  is  rarely  seen  on  the  lower  extremities  alone.  It  generally 
appears  in  crops  of  a  limited  number,  which  may  follow  each  other  at 
short  intervals,  and  extend  over  a  period  of  several  months  or  a  year. 
Proper  medication,  however,  will  certainly  abort  such  an  eruption  more 
or  less  promptly.  In  some  cases  of  an  erujition  composed  of  many  small 
pustules,  even  when  no  treatment  has  been  followed,  the  crusts  have  been 
known  to  reach  a  diameter  of  nearly  or  quite  one  inch  and  then  to  dry 
and  fall  off,  the  subjacent  ulcer  healing  meanwhile.  In  other  cases  the 
crusts  may  run  into  each  other  and  assume  a  horseshoe-shape.  This  erup- 
tion may  occur  during  the  first  year  of  syphilis,  but  is  generally  later. 

The  eruption  composed  of  large  crustaceous  ulcers  usually  presents  a 
limited  number  of  lesions.  Exceptionally  we  find  only  one  crust,  but  in 
some  cases  as  many  as  twenty  or  thirty.  The  diameter  of  a  crust  in  a 
case  that  has  been  long  neglected  may  be  even  more  than  two  inches. 
This  eruption  is  most  common  on  the  face  and  trunk,  but  may  occur  on 
the  extremities,  and  may  be  unsymmetrical.  The  lesions  appear  singly, 
or  two  or  three  may  be  developed  at  the  same  time  ;  they  grow  slowly  and 
pamlessly.  After  having  reached  a  diameter  of  an  inch  their  growth  is 
much  slower,  many  months  being  occupied  in  the  growth  of  a  crust  four 
inches  in  diameter.  The  ulcers  underlying  crusts  of  the  large  variety  of 
rupia  are  rather  deep,  but  rarely  involve  the  whole  thickness  of  the  derma. 
They  resemble  those  of  the  small  variety.  After  removal  of  one  of  the 
conical  crusts  a  thinner  one  of  a  similar  color  is  foi-med,  unless  the  surface 
is  thoroughly  stimulated.  Pi'ofuse  granulations  may  spring  up  which 
hinder  cicatrization.  Under  proper  treatment  the  ulcer  slowly  heals,  until 
a  deep  red,  glazed  spot  is  left,  which  gradually  becomes  thinner  and  lighter 
colored,  and,  finally,  a  white,  shining  surface  is  left,  which  is  depressed  be- 
low the  general  level,  and  around  which  a  rim  of  brown  pigment  remains 
for  months,  corresponding  with  the  former  areola.  These  cicatrices  are 
not  traversed  by  fibrous  bands,  but  scattered  over  tliem  are  minute  holes 
which  indicate  the  openings  of  sebaceous  follicles. 

The  [)rogno.sis  of  rupia  is  not  good  as  to  the  lesion  itself,  nor  as  to  the 
general  condition  of  the  patient.  In  some  rare  cases  of  precocious  evo- 
lution this  eruption  becomes  general,  the  lesions  being  large  and  numer- 
ous, and  the  general  condition  being  at  the  same  time  much  depressed. 
"Without  careful  and  vigorous  treatment,  this  malignant  form  of  syphilis 
may  be  fatal.  The  small  and  general  form  of  rupia,  although  accompanied 
by  cachexia,  may  be  cured  in  a  few  months.  The  ulcers  usually  occasion 
much  annoyance  and  suffering. 

The  large  form  of  rupia  is  of  considerable  gravity  and  calls  for  energetic 


.      THE    BULLOUS    STPHILIDE.  543 

local  and  constitutional  treatment.  Although  many  cases  recover,  death 
sometimes  occurs. 

A  question  of  diagnosis  cannot  arise,  since  no  simple  eruption  resembles 
rupia. 

During  the  visit  of  the  late  Prof.  Boeck,  of  Christiania,  to  this  country, 
he  treated  several  cases  of  syphilis  by  sy[)hilization,  using  pus  from  chan- 
croidal ulcers.  Upon  each  inoculated  spot  a  pustule  formed,  which  rai)idly 
became  covered  with  a  crust,  that  increased  by  laminae  and  in  fact  was 
rupial.  The  bodies  and  arms  of  two  men  were,  as  a  result,  covered  with 
rupial  crusts,  wliich  varied  in  diameter  from  one  to  three  inches  and  were 
identical  in  every  respect  with  those  caused  by  syphilis. 

The  Bullous  Syphilide. 

Much  confusion  has  been  introduced  into  syphilography  by  the  latitude 
given  to  the  term  pustule.  From  the  fact  that  some  forms  of  syphilitic 
pustules  are  not  situated  upon  an  elevated  base  and  are  large  and  globular, 
with  a  tendency  to  run  together,  the  existence  of  a  true  pem{)higoid  sy- 
philide has  been  asserted.  Further  study  has  proved  these  lesions  to  be 
pustular  and  not  bullous  ;  yet  in  some  cases  true  bullae  are  developed  on 
syphilitic  patients. 

The  eruption  begins  like  ordinary  pemphigus  by  an  effusion  of  serum 
beneath  the  epidermis,  which  slowly  increases,  until,  at  the  end  of  a  week 
or  two,  a  bulla  the  size  of  a  pea  is  formed.  The  serum  soon  becomes  tur- 
bid and  milky,  and  is  finally  converted  into  a  thick  yellow  pus.  The 
bullae  vary  in  size,  some  being  as  large  as  a  walnut.  They  are  surrounded 
by  a  dull  red  areola,  which  on  the  legs  may  be  due  to  effusion  of  blood. 
The  pus  soon  dries  into  a  dark,  greenish-black,  adherent  crust. 

Under  favorable  circumstances,  the  underlying  ulcer,  which  is  usually 
not  very  deep,  becomes  cicatrized  and  the  crust  falls  off,  leaving  deeply- 
pigmented,  more  or  less  atrophic  spots.  Sometimes,  however,  no  cliange  is 
pi'oduced  in  the  skin.  Without  treatment,  especially  in  cachectic  })atients, 
the  ulceration  increases  in  depth  and  extent,  and  the  lesion  may  then  re- 
semble rupia. 

This  eruption  occurs  mostly  on  the  forearms  and  legs,  where  it  may  be 
aggregated.  When  it  invades  tlie  trunk  it  is  more  copious  about  the  chest, 
but  is  generally  discrete.  Its  invasion  is  usually  very  slow.  Its  course  is 
also  very  chronic  and  unattended  by  any  marked  symptoms,  except  sore- 
ness and  sometimes  heat  in  the  bullae  and  ulcers.  Fresh  bullae  may  form 
during  the  course  of  the  eruption,  or  after  it  has  once  disap{)eared. 

The  bullous  syi)hilide  is  almost  always  a  late  eruption.  Mistakes  liave 
arisen  from  considering  certain  exceptionally  large  i)ustules,  or  those  which 
have  been  formed  by  the  fusion  of  several  of  the  variola-form  pustules,  as 
bullae,  and  calling  them  syphilitic  pemphigus.  These  bulkii  are  found  even 
at  a  late  period  only  in  those  who  have  Iiad  rei)eated  relapses  of  syphilis  in 
a  severe  form  and  in  those  having  visceral  lesions.  Tlie  oi)inion  has  been 
expres'Sed  that  an  eruption  of  this  kind  is  a  mere  coincidence,  a  [)emphigus 


544  SYPHILIDES. 

occurring  in  a  sypliilitic  suhject.  In  many  cases  tliere  are  certainly  no 
distingiiisliing  marks  between  the  bullous  eruption  of"  syphilis  and  pem- 
phigus, and  the  diagnosis  must  then  be  made  from  the  history  and  from 
the  associated  lesions  and  symptoms.  There  are  cases  in  which  the  syphi- 
litic history  is  clear,  and  the  bulla?  soon  form  rupial  crusts  and  leave  typi- 
cal tubercular  infiltrations. 

The  Tubercular  Syphilide. 

This  syphilide  consists  of  deeply-seated,  circumscribed  infiltrations  into 
the  skin,  resembling  in  appearance  the  large,  flat,  papular  syphilide,  and 
being,  in  reality,  nothing  more  than  an  exaggerated  form  of  the  latter 
lesion.  The  whole  thickness  of  the  skin  is  involved,  whereas,  in  the 
papular  syphilide,  the  deeper  layers  escape  ;  the  latter  is  a  secondary  mani- 
festation, while  the  tubercular  syphilide  is  a  tertiary  lesion. 

The  tubercular  syphilide  seldom  ulcerates,  but  disappears  by  interstitial 
absorption  ;  hence,  it  has  been  called  non-ulcer ative  or  resolutive. 

The  resolutive  tubercular  syphilide  may  appear  even  before  the  second 
year  of  syphilis  ;  it  is  usually  developed  between  the  third  and  sixth  years, 
but  may  be  seen  as  late  as  the  eighth  or  tenth  year,  and,  according  to  some 
authors,  even  as  late  as  the  fifteenth  or  twentieth.  It  is  usually  met  with 
in  cases  that  have  not  been  thoroughly  treated  at  the  outset.  Its  course 
is  very  chronic  and  marked  by  numerous  relapses,  many  years  passing 
while  it  travels  over  the  body.  It  causes  no  pain,  heat,  or  itching,  but 
merely  produces  thickening  of  the  skin.  AVhen  it  ai)pears  early,  it  may 
form  a  general  and  copious  eruption  ;  but  later,  the  tubercles  may  be 
limited  in  number  and  confined  to  a  single  region. 

The  tubercles  begin  as  deej)  red  spots,  which  slowly  increase  in  size  and 
thickness  until,  when  fully  developed,  they  have  a  diameter  of  from  one- 
half  an  inch  to  an  inch.  Sometimes  they  are  as  small  as  a  split  pea,  and 
again  they  are  more  than  an  inch  in  diameter.  Their  surface  is  flat  or 
rounded,  and  their  borders  are  sharply  defined.  The  smaller  lesions  are 
more  elevated  and  rounder  than  the  larger.  Upon  the  face,  they  often 
have  a  shining  appearance,  and  on  parts  where  the  epidermis  is  thick  and 
rough,  they  look  dull  and  dry.  The  color  of  the  tubercles  is  at  first  dark- 
red,  with  possibly  a  tinge  of  crimson,  but  frequently  it  is  a  light  pinkish- 
red.  Their  surface  is  usually  quite  smooth  and  free  from  scales,  but  some- 
times a  few  of  small  size  and  quite  adherent  are  seen.  Where  the  epi- 
dermis is  thick,  the  proliferation  is  occasionally  free,  giving  the  tubercles 
somewhat  the  appearance  of  psoriasis. 

Tiie  tubercles  first  appear  on  the  forehead  or  back  of  the  neck  near  the 
scapulae.  They  may  be  limited  to  these  regions,  or  may  invade  the  trunk, 
always  more  copiously  on  the  back  and  over  the  gluteal  regions.  In  front, 
they  are  generally  scattered,  but  in  some  cases  they  occur  in  large  numbers 
over  the  sternal  region,  on  the  borders  of  the  axilla?,  and  over  the  deltoid 
muscle.  They  are  more  copious  on  the  outer  aspects  of  the  extremities 
near  joints,  than  on  the  inner.     The  backs  of  the  hands  and  feet  are  spared, 


THE    TUBERCULAR    SYPHILIDE.  545 

but   tubercles  are  sometimes  developed  on  the  palms  and  soles,  and  soon 
pass  into  a  scaling  condition. 

The  course  of"  the  eruption  is  very  slow  ;  several  weeks  or  even  months 
may  pass  before  the  entire  body  is  covered.  When  the  eruption  is  gene- 
ral, the  tubercles  are  usually  disseminated  without  order,  rarely  showing  a 
tendency  to  circular  distribution.  Fresh  crops  often  fill  the  interspaces  of 
those  first  developed.  When  precocious,  the  eruption  may  be  very  copious. 
In  the  few  cases  we  have  seen  of  recurrence  of  this  eruption,  the  tubercles 
were  almost  in  contact  with  each  other.  Such  cases  are  rare,  and  belono- 
to  the  group  of  malignant  precocious  syphilides. 

An  eruption  of  tubercles  is  likely  to  be  general  when  occurring  within 
two  years  after  infection,  and  in  those  who  suflfer  from  a  severe  form  of 
syphilis,  or  who  have  been  improperly  treated  during  the  early  months. 
Far  more  commonly,  several  regions  are  successively  invaded. 

These  tubercles  are  prone  to  appear  in  an  irregularly  triangular  group, 
with  the  apex  at  the  glabella  and  the  base  near  the  margin  of  the  scalp. 
They  may  form  a  sort  of  corona  in  the  latter  region,  with  sometimes  a 
number  on  the  scalp  itself.  On  the  face,  they  sometimes  run  together 
and  form  patches.  Again,  several  tubercles  on  the  nose  blend  together 
and  extend,  to  the  cheeks,  forming  a  butterfly-shaped  patch.  When  the 
tubercles  spread  in  a  rapid  manner,  a  distinctly  elevated  margin  or  rim 
is  formed,  the  inclosed  patch  being  depressed.  In  this  serpiginous  form, 
the  whole  face  may  become  invaded.  The  centre  of  the  patch  gradually 
loses  its  color  and  becomes  thinner  until,  in  bad  cases,  a  cicatricial  tissue 
is  left.  This  process  is  usually  rapid,  and  then  slight  destruction  of  the 
skin  results  ;  when  it  is  slow,  more  or  less  atrophy  of  the  skin  is  produced. 
In  one  of  our  cases,  in  which  resolution  was  rather  rapid,  the  patient's 
face  was  covered  by  tubercular  rings,  which  merged  together,  the  inclosed' 
spaces  being  normal.  Some  authors  call  this  the  serpiginous  tubercular 
syphilide,  but  we  prefer  to  reserve  that  name  for  an  eruption  which  is 
serpiginous  by  ulceration. 

These  tubercular  rings  are  not  seen  in  all  cases;  in  some  the  lesion  ex- 
tends merely  at  certain  portions  of  its  margin.  Thus,  kidney-shaped 
growths  are  produced,  or  new  tubercles  may  form  and  finally  coalesce 
around  the  entii-e  periphery  of  the  patch.  Tubercular  patches  seated  on 
non-hairy  parts  are  smooth,  while  those  developed  in  regions  supplied  with 
hair  are  often  uneven  and  warty.  The  latter  condition  is  due  to  fusion  of 
the  tubercles  and  excessive  prominence  of  the  follicles  and  papillai.  Their 
surface  may  be  covered  with  a  crust  of  serum  and  epidermis,  or  the  scanty 
pus  may  dry  between  the  numerous  elevations.  Cases  of  invasion  of  the 
entire  scalp  in  this  way  have  been  recorded,  and  doubtless  many  of  the 
cases  of  framljcesia  of  the  old  writers  were  nothing  more  than  aggravated 
instances  of  this  vegetating  or  papillomatous  tubercular  syphilide.  It  has 
been  stated  that  the  pa[)ular  syphilide  may  undergo  a  similar  metamor- 
phosis. We  have,  therefore,  two  kinds  of  syphilide  vegetante,  or  papillo- 
viateuse,  y\\\c\\  differ  merely  in  degree,  a  papular  and  a  tubercular.  Tlie 
head  and  face  are  most  commonly  attacked,  but  the  trunk  about  the 
35 


546  SYPHILIDES. 

shoulders,  over  the  sternum,  and  in  the  inguinal  and  gluteal  regions  may 
be  invaded.  "When  this  syphilide  is  thus  altered  in  ciiaracter,  its  course 
is  even  more  chronic  than  usual. 

Several  peculiar  features  are  presented  by  this  syphilide  when  occurring 
on  the  face.  In  some  instances,  a  thin  yellow  crust,  which  is  quite  adhe- 
rent, covers  the  smooth,  shining  surface  of  the  tubercles.  This  may  be 
so  thicii  as  to  be  mistaken  for  pus  resulting  from  ulceration.  In  very 
chronic  cases,  it  may  form  a  rim  around  the  margin  of  the  tubercle,  the 
inclosed  surface  being  quite  scaly.  The  skin  generally  retains  its  supple- 
ness, although  its  entire  thickness  is  involved  by  the  infiltration  ;  but,  in 
some  cases,  especially  about  the  nose  and  on  the  lips,  it  becomes  as  hard 
and  unyielding  as  cartilage.  Much  annoyance  is  caused  by  the  immobility 
of  the  parts  and  by  the  hideous  deformity  which  often  results.  In  extreme 
cases,  the  skin  of  the  entire  face  may  become  thus  affected.  Although  a 
severe  lesion  and  often  very  rebellious,  the  effect  of  proper  treatment  in 
causing  absorption  of  the  infiltration,  and  in  restoring  the  natural  softness 
of  the  parts,  is  frequently  astonishing.  Where  this  complication  has  ex- 
isted for  a  long  time,  the  effect  of  medicine  may  bie  less  rapid. 

These  tubercles,  especially  on  the  face,  and  exceptionally  elsewhere, 
wherever  the  integument  is  soft  and  thin,  sometimes  undergo  colloid  degene- 
ration. "When  this  occurs,  the  color  of  the  tubercle  slowly  changes  to  a 
dull  brown,  the  lesion  becomes  less  resistant,  and  on  incision  a  soft,  gluey, 
non-diffluent  mass  is  revealed.  Such  a  tubercle  is  rather  more  elevated 
than  others,  and  appears  as  if  infiltrated  with  glue.  This  condition  is 
most  frequently  seen  on  the  forehead.  Usually  these  colloid  tubercles 
slowly  subside  by  absorption  of  the  cells,  leaving  a  depressed  cicatrix. 

Next  in  frequency  to  the  face,  the  shoulders  and  forearms  are  the  parts 
lattacked  by  the  tubercular  syphilide.  vSometimes  these  parts  are  primarily 
invaded. 

In  the  early  years  of  syphilis  the  tubercles  are  usually  disseminated  over 
the  body,  but  at  later  periods  successive  groups  appear  at  long  intervals  in 
different  regions.  The  eruption  may  thus  continue  for  many  years,  tlie 
general  health  deteriorates,  and  visceral  lesions  may  be  developed. 

The  course  of  the  eruption  de[)ends  almost  altogether  upon  treatment. 
In  its  early  stage  it  will  usually  be  dispersed  by  vigorous  measures.  A 
limited  relapse  is  very  likely  to  occur  in  case  of  inadequate  treatment. 
In  no  other  syphilitic  eruption  can  a  prognosis  be  made  with  equal  confi- 
dence. If  untreated  it  will  probably  invade  nearly  every  part  of  the  in- 
tegument. "We  have  seen  two  cases  in  which  more  than  six  hundred 
tubercles  formed  during  a  period  of  about  ten  years,  leaving  permanent 
cicatrices  u])on  the  face  and  body,  particularly  on  the  posterior  aspect  and 
■on  the  extremities.  Although  the  ala3  of  the  nose  and  the  lobes  of  the 
ears  were  destroyetl,  not  a  particle  of  ulceration  had  ever  occurred.  The 
atrophy  whicli  follows  this  eruption  probably  results  from  some  occult  change 
in  the  normal  cells  induced  by  the  presence  of  the  infiltrating  cells.  It  is 
certain  that  the  infiltration  and  the  tissue  framework  which  holds  it,  de- 
generate and  are  absorbed  at  the  same  time. 


THE    TUBERCULAR    SYPHILIDE.  547 

In  case  of  a  relajjse  a  group  of  pustules  is  usually  observed  in  some  one 
particular  region.  When  the  tubercles  are  scattered  over  the  body  we  may 
be  sure  that  the  period  of  infection  has  been  within  two  or  three  years. 
When  the  eruption  is  early  it  is  usually  symmetrical,  but  when  late  it  is 
often  unsymmetrical.  The  tubercles  are  usually  less  copious  with  each 
succeeding  outbreak,  but,  on  the  contrary,  cases  are  occasionally  met  with 
in  which  their  size  and  number  are  about  the  same  with  each  relapse.  The 
face,  back,  and  forearms  are  the  most  frequent  seats  of  relapses.  In  some 
cases  the  face,  and  exceptionally  the  scalp,  is  attacked  by  recurring  tuber- 
cles until  most  of  its  integument  is  left  in  a  cicatricial  state. 

After  full  development  the  course  of  these  tubercles  is  slow  and  without 
marked  features,  arid  they  are  generally  .amenable  to  treatment.  When 
they  retrograde  they  sometimes  first  sink  in  the  middle,  and  may  thus  be 
converted  into  tubercular  rings.  If  left  alone  they  remain  unchanged  for 
months.  Their  red  tinge  gradually  fades  to  brown,  they  flatten  and  finally 
disappear,  leaving  a  pigmented  spot.  This  syphilide  may  pass  away  with- 
out causing  disorganization  of  the  skin,  especially  if  treated  early.  Upon 
the  face,  and  where  the  tissues  are  soft  and  delicate,  cicatrices  are  apt  to 
result.  Hence  the  necessity  of  active  and  [n-olonged  treatment.  Tuber- 
cles that  have  remained  on  the  face,  uninfluenced  by  treatment,  for  two 
or  three  months,  almost  inevitably  leave  cicatrices.  On  other  parts  of  the 
body  they  may  remain  longer  without  leaving  any  deformity,  but,  as  a  rule, 
atrophy  of  the  skin  follows  when  they  have  lasted  three  months. 

In  some  cases  this  syphilide  ulcerates,  the  process  usually  being  limited 
to  a  portion  of  the  eruption.  This  may  occur  in  a  malignant  and  preco- 
cious manner,  ulcers  forming  with  great  rapidity.  Happily  such  cases  are 
rare.  When  ulceration  attacks  a  tubercle  a  yellow  crust  forms  on  its  sur- 
face, which  soon  covers  the  whole  tubercle,  and  attains  considerable  thick- 
ness. Its  color  gradually  becomen  greenish-black,  its  surface  is  rough,  and 
it  is  surrounded  by  a  dull  red  or  even  livid  areola.  Underneath,  and  co- 
extensive with  the  crust,  is  a  smooth  ulcer,  with  a  foul,  grayish-red  sur- 
face, sharply  cut  edges,  as  if  "  punched  out,"  and,  perhaps,  a  little  under- 
mined, secreting  an  ichorous  pus.  The  progress  of  the  case  varies  in 
diiferent  patients.  In  broken-down  subjects,  especially  from  alcoholism, 
the  ulcers  may  extend  and  merge  together,  forming  large  patches.  Under 
fjivorable  conditions  the  destructive  process  is  more  limited,  but  such  ulcers 
are  invariably  followed  by  depressed  cicatrices.  The  face,  thighs,  and 
forearms  are  the  parts  most  frequently  attacked.  On  the  face  particularly 
they  are. very  destructive,  and  leave  unsightly  scars. 

Strange  as  it  may  seem,  the  cicatrices  following  resolutive  tubercles  are 
often  as  well  marked  as  those  subsequent  to  dee[)  ulceration.  Wlien  reso- 
lution has  occurred,  without  any  damage  to  the  skin,  coppery  pigment  spots 
remain  for  a  time.  When  a  cicatrix  is  formed,  it  is  always  deeply  pig- 
mented and  surrounded  by  a  similar  areola.  These  cicatrices  form  very 
slowly.  After  complete  absori)tion  of  the  lesion  the  tissue  is  tolerably 
thick,  but  it  gradually  becomes  thinner  and  less  brown,  until  in  about  a 
year  there  remains  merely  a  soft,  glistening  membrane,  either  perfectly 


548  SyPHILTDES. 

smooth  or  perforated  witli  minute  holes,  the  seat  of  follicles.  Very  often 
a  narrow  coppery  areola  remains  for  a  long  time.  When  the  ulceration  has 
been  particularly  deep  and  extensive,  and  especially  when  it  has  occurred 
near  a  joint,  thick  and  long  fibrous  bands  sometimes  traverse  the  scar,  and 
in  some  cases  its  surfatre  is  studded  with  tubercles  of  false  keloid.  The 
occurrence  of  these  neoplasms  has  been  considered  diagnostic  of  lupus. 
As  a  matter  of  fact  they  are  developed  as  well,  though  less  frequently,  on 
syphilitic  cicatrices. 

The  prognosis  of  this  syphilide  is  good,  although  it  indicates  an  active 
and  persistent  form  of  sypiiilis.  Early  treatment  may  prevent  or  modify 
cicatricial  deformity  which  otherwise  may  be  extensive.  Persistence  in 
treatment  will  also  prevent  or  postpone  relapses. 

Ulceration,  complicating  this  eruption,  calls  for  the  exercise  of  the 
greatest  skill  and  care.  In  addition  to  the  use  of  proper  internal  and  local 
treatment,  the  nutrition  of  the  patient  should  be  improved  by  every  possi- 
ble means.  In  those  rare  cases  in  which  ulcei-ation  and  gangrene  attack 
the  tubercles  the  outlook  is  very  bad  ;  the  destruction  of  tissue  may  be  ex- 
treme, cachexia  may  appear,  and  a  typhoid  condition,  resulting  fatally,  may 
be  induced. 

This  syphilide,  when  occurring  in  the  secondary  period,  often  coexists 
with  lesions  of  the  intermediary  stage,  such  as  perionychia,  alopecia,  iritis, 
cerebral  affections,  testicular  lesions,  mucous  patches,  and  condylomata. 
Later  on  it  is  generally  accompanied  by  a  varying  degree  of  cachexia  and 
sometimes  by  visceral  lesions. 

Diagnosis This  syphilide  is  to  be  diagnosed  from  lupus  vulgaris,  ele- 
phantiasis Gra;corum,  carcinoma,  and  psoriasis.  Lupus  generally  begins 
in  early  life,  and  is  never  so  diffusely  scattered  as  the  tubercular  sy|)hilide. 
The  resemblance  is  seldom  striking  except  when  the  latter  is  limited  to  the 
face.  Lupus  tubercles  are  usually  more  irregular  in  outline  and  deeper 
than  those  of  syphilis.  They  are  pinkish-red  rather  than  brownish-red  as 
in  the  latter  disease.  Lupus  tubercles  are  more  commonly  studded  wij;h 
small  colloid  masses,  and  are  prone  to  ulcerate.  The  scars  left  by  lupus 
are  not  soft  and  thin  as  in  syphilis,  but  are  hai-d  and  seemingly  adherent 
to  the  subcutaneous  tissues.  The  crusts  of  lupus  are  not  so  regular  and 
round  as  those  of  the  tubercular  syphilide,  and  have  not  their  peculiar  dark, 
greenish-black  color.  The  underlying  ulcers  are  not  as  deep,  smooth,  and 
sharply  cut  as  those  of  syphilis. 

In  some  cases  of  true  leprosy  tubercles  occur,  which  resemble  in  size, 
shape,  and  color  those  of  syi)hilis,  but  they  are  usually  accompanied  by 
white,  anaesthetic  patches,  large  spots  of  brown  pigmentation,  nerve  swell- 
ings with  perverted  sensations,  large  nodular  infiltrations  and  ulcerations, 
or  other  manifestations  which  characterize  leprosy. 

Although  superficial  carcinomatous  tubercles  may  somewhat  resemble 
tliose  of  syphilis,  they  are  never  so  scattered,  and  are  always  much  larger, 
sometimes  involving  an  entire  region. 

The  tubercular  syphilide  occasionally  presents  two  appearances  which 
resemble  psoriasis.     The  first  is  when  the  tubercles  are  covered  with  an 


THE    GUMMOUS    SYPHILIDE.  549 

unusual  number  of  scales,  especially  on  the  outer  aspect  of  the  arms,  where 
psoriasis  is  prone  to  appear.  The  second  is  when  tlie  tubercles  undero^o 
inv'olution  and  form  rings.  Psoriasis,  however,  is  a  disease  beginning  in 
youth,  and  is  essentially  scaly.  The  tubercles  of  syphilis  are  infiltrations, 
and  though  some  may  be  covered  with  scales,  others  will  be  found  free  from 
them.  In  sypliilis,  again,  we  have  the  history  of  the  case,  and  perhaps 
other  manifestations  of  the  disease.  In  rare  cases  in  wliich  the  eruption 
is  limited,  and  the  liistory  obscure,  mercurial  treatment  settles  all  questions, 
since  it  cures  a  syphilide  and  does  not  influence  psoriasis. 

Some  authors  call  this  sy[)hilide  lupus  syphiliticus,  a  term  inapplicable 
for  reasons  already  given. 

The  Gum:mous  Syphilide. 

This  syphilide  is  almost  invariably  a  late  lesion,  and,  although  usually 
invading  the  skin,  it  always  begins  in  the  subcutaneous  connective  tissue. 
It  consists  of  tubercular  infiltrations,  some  as  small  as  a  pea  and  others 
several  inches  in  diameter.  AVhen  great  extent  of  tissue  is  involved,  the 
lesion  is  usually  composed  of  several  tumors  merged  together.  This  is  not 
always  the  case,  Fournier  having  i-eported  a  single  tumor  fourteen  centi- 
metres in  length,  eight  to  ten  in  breadth,  and  from  two  to  six  in  thickness. 
Unlike  other  syphilides,  in  which  the  specific  neoplasm  is  diflfused,  this 
lesion  is  a  true  circumscribed  tumor. 

This  syphilide  is  particularly  prone  to  appear  in  parts  where  the  con- 
nective tissue  is  loose  and  abundant.  It  may  be  limited  to  the  connective 
tissue,  but  on  invading  the  skin  it  usually  ulcerates.  In  the  former  case 
we  ap{)ly  to  the  syphilide  the  term  gummous  or  gummous  tumor,  in  the 
latter  case  we  call  it  a  gummous  ulcer. 

The  [)rogress  of  the  lesion  varies  according  to  the  condition  of  the  parts 
upon  which  it  is  developed;  in  thick  and  copious  adipose  or  cellular  tissue 
the  tumors  may  remain  a  long  time  without  attacking  the  skin;  under 
contrary  conditions  or  above  a  bony  surface  implication  of  the  skin  is  early 
and  the  bone  itself  may  be  eroded  superficially  or  deeply.  Sometimes  the 
muscles  are  exposed  by  complete  destruction  of  sujierjacent  tissues.  Blood- 
vessels, nerves,  and  sometimes  bursas  may  be  involved  by  extension  of 
the  lesion. 

We  shall  study  this  syphilide  in  its  three  stages :  of  tumefaction,  of  ulcer- 
ation, and  of  repair. 

In  the  first  stage  we  find  from  one  to  six  small  tumors,  which  appear 
simultaneously  or  in  succession  and  run  an  idolent  course.  In  exceptional 
cases,  when  the  eruption  appears  during  the  early  years  of  syphilis,  the 
tumors  may  be  numerous,  their  invasion  quite  ra|)id,  and  the  attendant 
local  and  general  symptoms  w'ell  marked.  Cases  have  been  re])orted  in 
which  there  were  twenty,  tliirty,  and  even  forty  tumors,  and  Lisfranc  has 
recorded  one  instance  in  whicii  there  were  one  hundred  and  sixty.  When 
they  appear  early  they  are,  as  a  rule,  numerous  and  synmietrical ;  when 
occurring  later,  the  reverse  is  true. 


550  SYPHILIDES. 

These  small  tumors  are  painless  and  attended  by  slight  tenderness. 
Tiieir  growth  is  generally  slow.  At  first  they  are  freely  movable ;  they 
soon  become  attached  to  the  surrounding  tissues,  especially  when  seated 
over  bony  surfaces  or  in  regions  where  the  connective  tissue  is  scanty. 
They  give  to  the  finger  a  sensation  of  moderate  firmness,  retaining  their 
shape  under  pressure,  having  neither  the  elasticity  of  a  fatty  tumor  nor 
the  hardness  of  scirrhus.  In  many  cases  they  tend  to  invade  the  skin 
rather  than  the  deeper  tissues.  Their  superficial  growth  is  first  shown  by 
slight  reddening  of  the  overlying  skin,  which  rapidly  becomes  thickened 
and  less  supple.  Finally  we  observe  a  tubercular  infiltration,  round  or 
oval  in  shape,  perhaps  slightly  elevated,  of  a  deep  coppery-red  color  and 
surrounded  by  a  well-marked  hypertemic  areola.  They  may  remain  in  this 
condition  for  many  weeks  or  even  months,  and  still,  under  treatment, 
undergo  resolution.  Generally,  however,  their  firm  structure  slowly 
breaks  down  until  finally  fluctuation  may  be  detected.  In  many  cases  the 
soft  yielding  character  of  the  tumor  gives  a  false  impression  that  pus  is 
confined  beneath  the  skin.  On  incision  of  such  a  tumor  a  small  quantity 
of  thick,  bloody  pus  escapes  and  a  soft  mass  is  found,  but  no  cavity  like 
that  of  an  abscess.  In  case  of  true  fluctuation,  however,  there  is  an  actual 
cavity  containing  fluid,  resulting  from  disintegration  of  the  tumor.  Surgi- 
cal interference  is,  however,  seldom  required.  The  cavity,  in  most  cases, 
opens  spontaneously,  either  like  a  furuncle  by  a  single  aperture  or  by 
ulceration  at  several  distinct  points. 

The  minute  changes  leading  to  this  condition  are  of  interest.  The  im- 
mediate product  of  the  death  of  the  subcutaneous  neoplasm  is  a  thick  gummy 
mass,  the  intermingled  pus  being  supplied  by  the  surrounding  parts  which 
are  secondarily  inflamed.  The  destructive  process  goes  on  very  slowly 
until  after  the  occurrence  of  ulceration.  The  small  ulcers  first  formed  are 
deep  and  sharply  cut  ;  they  extend  in  all  directions  until  the  destruction  of 
the  entire  neoplasm  results  in  the  formation  of  what  may  be  called  a  typical 
gummous  ulcer.  Such  an  ulcer  is  either  round,  oval,  or  gyrate  from  fusion 
of  the  small  ones,  and  sharply  cut  as  if  punched  out.  Its  floor,  which  is 
greenish-red,  or  sometimes  greenish-black,  is  uneven  and  bathed  with  sani- 
ous  fetid  pus.  The  edges  of  the  ulcer  are  thickened,  and  around  them  is 
generally  an  extensive  areola  of  hyperaemia,  which  may  be  so  persistent  as 
to  give  the  impression  that  it  also  is  the  seat  of  gummatous  infiltration. 
The  course  of  such  ulcers  varies  with  the  care  they  receive.  Sometimes 
they  take  on  phagedenic  action,  invading  extensive  surfaces  and  causing 
profound  or  even  fatal  cachexia.  They  may  remain  in  an  indolent  condi- 
tion for  months,  discharging'  a  foul  secretion,  showing  no  reparative  ten- 
dency, and  inducing  great  oedema  of  surrounding  parts.  Groups  of  ulcers 
may  be  found  connected  by  narrow  bands  of  reddened  and  detached  skin, 
wliose  nutrition  is  but  feebly  sustained  by  the  superficial  vessels  ;  hence 
these  bands  soon  melt  aAvay  and  expose  the  subjacent  ulcerating  surface. 

The  depth  of  the  ulcers  depends  largely  upon  the  thickness  of  the  origi- 
nal infiltration.  In  some  cases  the  gummy  deposit  is  confined  to  the  cel- 
lular tissue  just  below   the  papillary  layer  of  the   skin  and   the  resulting 


THE    GUMMOUS    SYPHILIDE.  551 

ulcer  is  relatively  shallow.  In  other  cases  it  is  more  deeply  seated  below 
the  derma,  and  may  be  exposed  by  scraping  oif  the  upper  la3'ers. 

In  its  early  stage  the  tissue  of  the  gumma  is  of  a  reddish-yellow  color, 
and  has  a  soft  consistence  ;  at  a  later  period  it  looks  dry,  firm,  grayish-red 
and  non-vascular.  The  changes  in  its  appearance  are  largely  due  to 
gradual  compression  and  obliteration  of  the  bloodvessels.  Repair  can  never 
take  place  until  complete  removal  of  this  tissue,  which  must  be  hastened 
by  local  as  well  as  general  treatment.  The  progress  towards  cure  is  espe- 
cially slow  where  the  surface  of  muscles  has  been  exposed  and  when  the 
destructive  action  has  extended  even  to  the  tissues  of  the  intermuscular 
septa. 

Under  treatment  the  foul  surface  of  the  ulcer  is  supplanted  by  granula- 
tions which  eventually  cicatrize.  Sometimes  these  granulations  become 
exuberant  and  rise  above  the  normal  level.  As  the  ulcer  heals,  the  sur- 
rounding redness,  which  on  the  legs  may  be  of  a  purple  tint,  gradually 
diminishes  and,  when  the  cicatrix  is  formed,  there  remains  a  dull  coppery 
areola,  which  may  persist  for  many  years. 

The  cicatrices  of  gummous  ulcers  differ  according  to  the  depth  of  the 
destructive  process.  When  the  ulceration  has  been  superficial  the  scars 
are  slightly  depressed,  thin,  parchment-like  and  of  a  dead  white  color. 
All  such  cicatrices  become  blanched  from  their  centre  outwards. 

The  cicatrices  of  deep  ulcers  are  much  depressed  and  often  very  uneven, 
owing  to  fibrous  bands  and  nodules.  Some  are  also  peculiar  in  being  ad- 
herent to  the  dee[)er  parts.  In  case  the  gummous  ulceration  has  involved 
the  superficial  portion  of  the  bone,  the  cicatrix  adheres  as  firmly  as  did 
the  periosteum  to  the  osseous  surface.  In  other  cases  where  much  destruc- 
tion of  bone  has  occurred  no  cicatrix  at  all  is  formed,  the  eroded  surface 
being  surrounded  by  a  firmly  attached  fibrous  band,  which  represents  the 
margin  of  what  might  have  been  a  cicatrix. 

This  syphilide  may  appear  on  the  scalp,  on  the  face,  particularly  about 
the  mouth  and  nose,  and  also  on  tlie  neck.  It  attacks  the  extremities, 
generally  near  the  joints,  and  those  parts  where  the  integument  is  soft  and 
the  connective  tissue  abundant ;  the  palms  and  soles  therefore  escape.  It 
invades  the  back  oftener  than  the  anterior  aspect  of  the  trunk  and  is  seldom 
seen  on  tlie  lower  part  of  the  abdomen.  The  following  is  a  table  of  fifty- 
nine  cases  in  whicli  Fournier  observed  the  locality  of  the  ulcers. 


The  tliighs    . 

.       5 

The  sub-hyoid  region 

.       1 

The  sternum 

.       2 

The  neck 

.      4 

The  lips 

.       1 

The  feet    .          .          . 

.       1 

Intet^inuent  of  penis 

2 

Metatarsal  region 

.       1 

Scrotum 

.       5 

Cheeks      .... 

2 

Legs      .... 

.     11 

Forearms 

.       3 

Back     .... 

.       1 

Eyelids     .... 

.       2 

Fingers 

.       3 

Labia  majora    . 

.       1 

Arras    .... 

.       4 

Tliighs      .... 

.       1 

Groin    .... 

.       1 

Face           .... 

.       4 

Thj)rax 

2 

Scalp        .... 

.       1 

Breast  .... 

.       1 

— 

Total  .         .         .         .     5i) 


552  SYPHILIDES. 

Gummy  tumors  [)resent  certain  peculiarities  in  different  regions  of  the 
body,  and  may  be  complicated  by  intercurrent  morbid  processes.  Ery- 
sipelas may  attack  the  ulcers,  especially  when  seated  on  the  head  or  ex- 
tremities. The  oedema  which  accompanies  gummous  ulcers  of  the  leg 
may  be  so  severe  and  chronic  as  to  induce  a  condition  similar  to  elephan- 
tiasis Arabum.  Again,  in  various  parts  of  the  body  the  a{)pearance  of  the 
ulcers  may  be  totally  changed  by  a  serpiginous  or  phagedenic  process. 

Gummy  tumors  of  the  scalp  are  seldom  isolated  and  movable  ;  usually 
the  entire  integument  is  thickened,  and,  although  at  first  movable  over  the 
bones,  soon  becomes  adherent.  Small  ulcers  form  at  follicular  openings, 
and  gradually  increase  in  size.  Sometimes  the  outer  table  of  the  skull  is 
destroyed,  and  in  other  cases  the  whole  thickness  of  bone  becomes  ne- 
crosed ;  the  dura  mater,  however,  resists  the  destructive  action  in  a  remark- 
able manner,  and  is  rarely  involved.  The  scalp  over  the  frontal  and 
parietal  bones  is  most  commonly  attacked,  and  not  infrequently  the  fore- 
head, chiefly  towards  the  median  line,  is  invaded.  The  secretions  from 
ulcers  occurring  in  the  latter  situation  sometimes  accumulate  between  the 
bone  and  the  integument,  and  produce  much  swelling  in  the  supra-orbital 
regions.  The  eyes  may  become  closed  by  swelling  of  the  lids  caused  in  a 
similar  way;  A  more  serious  complication  of  these  ulcers  of  the  scalp  is 
erysipelas,  which,  in  some  instances,  as  already  stated,  may  excite  repara- 
tive action. 

U[»on  the  face  we  find  both  the  movable,  subcutaneous  tumor  and  the 
infiltration  which  involves  the  deeper  layers  of  the  skin.  Such  swellings, 
being  discovered  here  earlier  than  in  other  regions,  usually  receive  treat- 
ment soon  enough  to  prevent  their  reaching  an  extraordinary  size.  In 
neglected  cases,  however,  the  infiltration  may  be  very  extensive.  Caze- 
nave  has  reported  an  instance  in  which  the  face  was  so  distoi'ted  as  to  be 
unrecognizable,  having  a  leonine  expression  as  in  elephantiasis  Grsecorum. 
We  have  seen  a  case  in  which  the  nose,  lips,  and  chin  were  excessively 
hypertrophied.  The  peculiarities  of  tliis  syphilide  in  the  stage  of  tumefac- 
tion are  similar  here  and  elsewhere,  except  that  about  the  lips  and  nose  it 
sometimes  has  a  cartilaginous  hardness.  Hyperasmia  is  soon  seen,  and  the 
progress  towards  ulceration  is  quite  rapid.  The  resulting  ulcer  has  the 
l)ecidiarities  of  similar  syphilitic  lesions  in  other  regions.  The  crusts, 
which  frequently  form,  have  a  greenish-black  color.  About  the  nose  much 
destruction  is  often  produced,  either  limited  to  the  skin  or  involving  the 
cartilage  and  the  bones.  Erysipelas  may  complicate  gummous  ulcers  of 
this  region,  and,  in  rare  cases,  phagedama,  which  has  been  known  to  de- 
stroy the  greater  jjart  of  the  fixce. 

The  gummous  syphilide  of  the  arms  and  forearms  is  not  especially  pecu- 
liar, but  in  most  cases,  when  it  is  seated  over  nerves,  severe  neuralgias 
are  produced.^     In  somewhat  rare  cases   gummy  deposit  in  the   fingers 

•  Gummata  may  be  situated  in  almost  any  region  over  a  nerve  and  may  then 
canse  pain.  Ricord  reports  one  case  in  which  a  gumma  of  the  size  of  a  chestnut, 
si-atcd  in  the  groin,  caused  pain  in  the  crural  nerve;  and  another  in  which  two 


THE    GUMMOUS    SYPHILIDE.  553 

produces  a  swelling  resembling  that  occurring  in  a  specific  lesion  called 
dactylitis.  Although  prone  to  appear  near  the  joints,  this  syphilide  sel- 
dom invades  the  articulations  themselves.  In  one  case,  however,  a  gum- 
mous  tumor  over  the  sterno-clavicular  articulation  ulcerated,  destroyed  the 
joint  and  perforated  the  lung,  death  resulting.  In  another  case,  a  gumma, 
the  size  of  a  hen's  a^^,  was  developed  in  an  intercostal  space,  eroded  the  bone 
and  perforated  the  pleura.  The  liability  to  this  accident,  in  the  case  of 
gummata  situated  on  the  side  of  the  thorax,  should  lead  to  the  adoption  of 
very  vigorous  treatment. 

Gummata  not  infrequently  form  in  the  female  breast,  less  commonly  in 
both  breasts.  The  importance  of  their  diagnosis  is  here  very  great ;  failure 
to  recognize  their  true  character  may  lead  to  unnecessary  surgical  inter- 
ference. They  appear,  as  elsewhere,  slowly ;  they  are  only  moderately 
hard  and  are  painless.  There  is  no  retraction  of  the  nipple,  and  the  axil- 
lary glands  are  unaflfected.  The  ulceration  which  occurs  is  characteristic 
and  quite  unlike  the  indurated,  fungoid  ulceration  of  cancer.  In  all  cases 
of  limited  tumors  of  the  breast,  a  suspicion  of  their  gummous  ciiaracter 
should  be  entertained,  especially  when  the  patient  is  young  or  of  middle 
age.  A  mistake  is  liable  to  occur  only  when  the  gumma  is  very  large  and 
of  unusual  depth. 

The  cellular  tissue  of  the  buttocks  being  very  copious,  gummata  of  the 
gluteal  regions  often  attain  remarkable  size  and  depth.  We  have  seen 
several  instances  in  which  the  sharply-cut  walls  of  the  ulcer  led  down  to  a 
base  four  inches  from  the  surface  of  the  skin.  The  genitals  and  thighs 
are  very  apt  to  be  attacked  by  these  tumors,  which,  upon  the  penis,  scro- 
tum, and  labia  majora,  are  often  almost  ligneous  in  consistence.  The  peri- 
naeum  is  sometimes  the  seat  of  circumscribed  gummy  deposit.  We  have 
seen  one  case  in  which  urethral  fistula  resulted  from  ulceration  of  a  gumma 
in  this  region. 

Little  need  be  said  of  gummy  tumors  of  the  thighs  beyond  the  fact 
that  they  are  often  of  very  large  size.  When  they  occur  on  the  legs,  the 
question  of  diagnosis  is  particularly  interesting.  The  ulcerating  gummy 
tumor  is  usually  seen  on  the  upper  and  middle  thirds  of  the  leg,  and  wiiere 
the  connective  tissue  is  abundant,  differing  markedly  from  simple  ulcers, 
which  most  commonly  form  on  the  lower  third,  and  over  a  bony  surface. 
They  may  ap{)ear  lower  down,  but  usually  where  the  tissues  are  lax,  and 

such  tumors,  seated  in  the  course  of  the  ulnar  nerve,  provoked  severe  pain  in  the 
forearm  and  in  the  two  inner  fingers.  NClaton  reports  two  cases  ;  in  one  a  gumma 
of  the  axilla,  besides  causing  neuralgia  in  the  wliole  arm  and  shoulder,  produced 
by  compression  a  souffle  in  the  axillary  artery,  venous  stasis,  and  oedema  of  the 
extremity.  The  tumor  speedily  subsided  under  the  use  of  iodide  of  potash.  The 
second  case  was  that  of  a  lady  who  had  consulted  several  physicians  on  account 
of  pain  in  the  foot,  which  was  found  by  N61aton  to  be  caused  by  a  gumma  com- 
pressing the  plantar  nerves.  In  a  case  seen  by  Fournier,  two  gummata  were 
found,  one  upon  the  median  and  the  other  upon  tlie  radial  nerve,  each  of  which 
was  the  cause  of  \>a.\\\,  numbness,  and  muscular  weakness.  In  another  case,  seen 
by  tlie  same  autlior,  a  small  gumma  over  the  track  of  the  supra-orbital  nerve  gave 
rise  to  considerable  pain. 


554  SYPHILIDES. 

seldom  over  a  bony  sui-face.  They  are  often  multiple,  but  more  than  four 
are  rarely  observed.  They  select  the  sides  of  the  leg  rather  than  the  pos- 
terior aspect.  They  are  always  surrounded  by  intense  hyperaemia,  and 
frequently,  late  in  their  course,  they  resemble  non-specific  ulcers,  especially 
the  varicose.  Their  edges  become  rounded  and  callous,  and  their  surface 
is  studded  with  granulations,  thus  losing  their  characteristic  features. 

In  some  cases  of  precocious  evolution,  groups  consisting  of  six  or  a 
dozen  of  these  gummous  tumors,  form  upon  the  legs,  especially  near  the 
knees,  less  frequently  upon  the  buttocks,  and  even  on  the  forearms  and 
forehead.  They  rapidly  invade  the  skin  and  form  ulcers,  which  are  at 
first  extraordinarily  active,  but  soon  pass  into  a  chronic  state. 

The  extensive  hyperaimia  which  usually  accompanies  these  ulcers  of 
the  leg,  is  the  cause  of  localized  osdema.  In  very  chronic  and  extensive 
ulceration  the  oedema  begins  about  the  ankle,  and  involves  a  portion  or 
the  whole  of  the  leg,  which  becomes  swollen,  hard,  and  brawny,  the  in- 
tegument above  the  ankle  being  thrown  into  folds.  This  condition,  which 
is  very  obstinate,  and  altogether  resists  internal  treatment,  resembles  ele- 
phantiasis Ai'abum.  When  their  edges  become  thickened  and  callous, 
these  ulcers  do  not  extend  rapidly,  but  persist  for  many  years.  Their 
base  is  covered  by  a  layer  of  greenisli-black  slough,  and  from  it  exudes  a 
thin,  fetid,  bloody  secretion. 

Phagedaina  is  hap[)ily  an  infrequent  complication  of  this  syphilide.  In 
broken-down  subjects  the  ulceration  rapidly  destroys  the  skin  and  subja- 
cent tissues,  sometimes  even  denuding  the  bones.  The  process  is  ex- 
tremely painful,  and  is  attended  by  constitutional  reaction,  which  some- 
times reaches  a  typhoid  condition.  The  parts  most  subject  to  this 
complication  are  the  face,  feet,  and  genitals.  Unless  promptly  checked 
there  may  be  great  destruction  of  tissue. 

This  syphilide  may  appear  within  the  first  year  of  syphilis,  but  it  is 
generally  a  late  symptom,  appearing  at  any  time  from  the  third  to  the 
fifteenth  or  twentieth  year.  Fournier  reports  a  case  of  gummy  tumor  of 
large  size,  which  was  developed  fifty  years  after  infection,  and  was  cured 
by  iodide  of  potash. 

The  prognosis  is  influenced  by  the  date  of  the  appearance  of  the  syphi- 
lide, its  extent,  and  the  general  condition  of  the  patient.  Its  early  and 
malignant  appearance  indicate  an  active  and  severe  form  of  syphilis,  in 
which  visceral  gummata  are  to  be  feared.  Although  only  one  or  two 
gummous  tumors  or  ulcers  may  be  present,  and  the  general  health  is  not 
much  afi^ected,  thorough  internal  treatment  is  none  the  less  necessary. 

The  diagnosis  is  to  be  made  in  its  stages  of  tumefaction  and  of  iilcera 
tion.  When  it  exists  as  a  movable,  subcutaneous  tumor,  it  may  be  mis- 
taken for  a  fibrous,  a  sarcomatous,  or  a  fatty  tumor,  or  perhaps  an  en- 
larged ganglion.  The  syphilitic  lesion  is  usually  multii)le,  and  is  not 
compressible  like  the  fatty  tumor,  nor  as  hard  as  the  sarcoma.  Sarcomata 
tend  to  attach  themselves  to  subjacent  parts;  tiie  gummy  tumors  invade 
the  skin.  The  history  of  the  case,  the  absence  of  pain  in  the  tumor,  and 
its  situation,  may  be  of  assistance.     Tumor-like  infiltrations  upon  the  face, 


THE    SERPIGINOUS    SYPHILIDE.  555 

in  the  female  breast,  about  the  genitals,  near  joints,  and  wherever  connec- 
tive tissue  is  abundant,  should  always,  in  case  of  doubt,  be  subjected  to 
specific  treatment.  Numerous  cases  have  occurred,  particularly  with 
French  surgeons,  in  which  mixed  treatment  has  dissipated  tumors  con- 
demned to  excision. 

Tlie  general  appearance,  situation,  and  history  of  gummatous  ulcers  are 
generally  sufficient  to  establish  their  character ;  but  sometimes,  especially 
on  the  face  and  lower  extremities,  they  may  be  confounded  with  ulcerating 
lupus,  or  with  simple  eczematous  or  varicose  ulcers.  Lupus  begins  as 
small  tubercles  of  the  skin,  which  slowly  ulcerate  and  become  partially 
incrusted,  and  it  extends  by  the  formation  of  new  tubercles,  which  in  turn 
ulcerate.     Lupus  usually  begins  in  early  life,  and  on  the  nose. 

Eczematous  ulcers  are  always  preceded  by  eczema  of  the  skin,  which 
lies  tense  over  a  bony  surface.  They  are  painful,  superficial,  always  ac- 
companied by  a  good  deal  of  inflammation,  and  are  seated,  as  a  rule,  on 
the  lower  third  of  the  leg.  Similar  general  features  are  observed  in  vari- 
cose ulcers,  together  with  enlarged  veins  and  more  or  less  cedema. 

The  Serpiginous  Syphilide. 

This  syphilide  creeps  over  large  surfaces  by  ulcerating  at  the  periphery 
of  patches  while  it  heals  in  the  centre.  It  may  occur  as  early  as  the 
second,  or  as  late  as  the  tenth  or  fifteenth  year  of  syphilis,  possibly  later. 
Its  course  is  very  chronic,  and,  although  unattended  by  pain,  it  frequently 
causes  great  inconvenience.  Its  efil'cts  on  the  skin  may  be  slight,  or  it 
may  leave  disfiguring  cicatrices.  There  are  two  varieties  of  tliis  lesion,  a 
superficial  and  a  deep. 

Tlie  superficial  serpiginous  syphih'de  begins  as  a  pustule,  generally  of 
the  impetigo-form  or  of  the  variola-form  syphilide.  In  its  early  stage  it 
consists  of  a  superficial  ulceration,  which  has  no  characteristic  features 
indicative  of  its  future  course,  but  which  extends  in  the  shape  of  a  round 
or  oval  patch.  If  treatment,  and  particularly  local  treatment,  is  not  em- 
ployed, the  process  continues  and  crusts  form,  until  the  patch  reaches  a 
diameter  of  about  two  inches  ;  granulations  then  spring  up  from  the  centre, 
and  the  crust  falls  off  except  at  the  periphery,  where  it  adheres  as  an  en- 
circling ring.  Thus  is  formed  not  a  continuously  incrusted  surface,  but  a 
ring  of  crusts  inclosing  a  more  or  less  hypera^mic  area  of  a  round  or  oval 
shape.  The  color  of  the  crusts  is  usually  yellowish-brown  or  greenish- 
black,  and  their  thickness  about  one-tenth  of  an  inch.  The  underlying 
surface  is  smooth,  of  a  grayish-red '  color,  and  ulcerated  at  the  margins. 
Around  the  edges  is  a  narrow,  red  areola.  The  ulcerative  process  slowly 
progresses  at  the  margins  of  the  patch,  a  rim  of  crust  at  the  same  time 
forming.  Healing  of  the  inclosed  surface  keeps  pace  with  the  peripheral 
extension  of  the  ulceration,  so  that  the  width  of  the  crust,  varying  from 
half  an  inch  to  an  inch,  is  steadily  maintained.  Tlie  centre  of  this  surface 
is  l)Uu)ched,  its  margins  are  always  red,  and  tliey  merge  gradually  into  the 
ulceration.     This  process  may  continue  many  years,  and  involve  extensive 


556  SYPniLiDES. 

surfaces.  When  healing  begins,  the  crusts  become  harder  and  darker,  and 
the  redness  of  the  central  patch  and  of  the  ai'eola  diminishes.  Then  seg- 
ments of  crusts,  having  been  lifted  by  the  granulations  beneath,  fall  off, 
and  expose  an  ulcerated  ring.  Unless  cauterized  with  a  solution  of  nitrate 
of  silver,  as  it  should  be,  it  may  persist  for  a  long  time.  At  first  the 
ulcer  generally  increases  throughout  its  whole  periphery ;  subsequently,  it 
may  increase  only  in  one  direction,  thus  becoming  oval  or  reniform.  The 
extension  of  the  ulcer  is  largely  influenced  by  the  tissues  on  which  it  is 
seated.  Thus  an  ulcer  on  the  inner  surface  of  the  forearm  creeps  up  the 
arm  much  more  rapidly  than  towards  its  outer  surface,  where  the  tissues 
are  firmer ;  and  thus  a  long,  oval  ulcer  is  formed.  A  similar  occurrence 
is  observed  on  the  thighs,  while  on  the  face,  where  the  tissues  are  more 
uniform,  the  ulcers  are  generally  round.  The  result  of  this  superficial 
ulceration  may  be  simply  coppery  pigmentation,  which  lasts  several 
months,  or  very  slight  atrophy  of  the  skin.  The  ulceration  may  even  be 
extensive  and  protracted,  and  yet  induce  wonderfully  little  structural 
change. 

The  deep  serjiiginoi(s  syphilide  has  for  its  focus  of  ulceration,  one  of  the 
late  or  tertiary  lesions,  sucii  as  a  tubercle,  an  ecthyma- form  pustule,  or  an 
ulcerating  gumma.  Whatever  the  starting  point,  there  is  soon  developed 
a  deep,  sharply-cut,  active  ulcer,  with  undermined  edges  and  a  coexten- 
sive crust.  This  ulcer  increases  in  size,  more  or  less  rapidly,  until  it 
attains  a  diameter  of  two  or  three  inches,  when  changes,  similar  to  those 
obs(;rved  in  the  superficial  variety,  may  occur.  The  crust  becomes  thin 
at  its  centre,  and  thick  at  its  margin  ;  the  thin  portion  soon  falls  off, 
leaving  a  round,  deep-red  cicatrix,  surrounded  by  a  thick,  greenish-black 
crust,  less  than  an  inch  in  width  and  quite  thick.  When  this  syphilide  is 
fully  developed,  and  has  attained  a  diameter  of  from  four  to  six  inches,  its 
changes  are  more  marked.  In  the  centre  is  a  round  or  oval  patch  of 
cicatricial  tissue,  having  a  coppery-red  color,  and  as  yet  firmly  attached 
to  the  subcutaneous  connective  tissue.  This  is  completely  inclosed  by  a 
ring  of  crust.  Tlie  ulcerative  process  is  not  equally  active  at  all  parts  of 
the  ring,  hence  result  certain  modifications  in  the  shape  of  the  crust.  The 
ulcerating  ring,  which  encircles  the  central  cicatrix,  forms  a  furrow  half 
an  inch  to  one  inch  in  width,  and,  at  its  most  active  portions,  a  line  or 
more  in  depth  ;  it  has  a  foul,  grayish-red  floor,  and  sharply-cut,  somewhat 
everted,  and  undermined  edges,  which  have  a  deep  red  color,  and  are 
continuous  with  an  areola  of  similar  tint.  Portions  of  this  ulcerating 
furrow  may  be  partially  filled  by  granulations,  or  even  entirely  cicatrized. 
Over  the  more  active  segments,  there  is  a  yellowish-brown  crust,  slightly 
depressed  below  the  level  of  the  skin,  and  which  may  be  raised  as  a  film 
from  the  surface.  In  portions  further  advanced  towards  healing,  the 
crust  is  thicker,  harder,  slightly  above  the  surrounding  level,  and  of  a 
greenish-brown  color;  continuous  with  it,  on  parts  where  the  process  is 
quiescent,  or  where  healing  is  nearly  complete,  the  crust  is  greenish-black 
in  color,  is  hard  and  adherent,  and  its  base  on  a  level  with  the  skin.    Thus 


THE    SERPIGINOUS    SYPHILIDE.  55Y 

we  can  always  infer  the  age  of  the  ulceration  from  the  size,  color,  con- 
sistence, thickness,  and  prominence  of  the  crusts. 

Relapses  may  occur  by  ulceration  of  the  cicatrix,  sometimes  destroying 
the  whole  of  it.  This  occurs  most  frequently  in  debilitated  and  jworly- 
nourished  persons,  and  in  those  who  use  alcohol  to  excess.  The  cicatrix 
following  such  a  relapsing  ulcer  is  very  rough  and  unsightly.  Sometimes 
the  cure  is  retarded  by  repeated  relapses  at  the  margins  of  large  ulcers, 
segments  which  had  healed  being  again  attacked  by  the  ulcerating  process, 
or  again,  parts  more  remote  may  be  attacked. 

The  course  of  this  syphilide  is  always  slow,  often  occupying  many  years. 
In  some  cases  it  is  accompanied  by  profound  cachexia,  while  in  others 
there  is  no  disturbance  of  the  general  health. 

This  syphilide  is  of  rather  rare  occurrence.  It  may  appear  as  earlv  as 
the  third  year,  but  generally  later,  even  up  to  the  fifteenth  year  after  in- 
fection. It  appears  usually  on  the  inner  surface  of  the  forearms  and  arms, 
on  the  breast,  and  on  the  legs.  It  causes  little  if  any  pain,  but  frequently 
gives  great  annoyance  when  near  joints.  When  the  resulting  cicatrices 
are  small  they  are  generally  thin  and  parchment-like ;  but,  if  large,  they 
are  thick,  uneven,  and  often  traversed  by  fibrous  bands,  and  covered  by 
tubercles  of  false  keloid.  Often,  however,  even  the  large  scars  are  thin, 
a  fact  of  importance  in  making  a  diagnosis  between  this  syphilide  and 
serpiginous  lupus.  Blanching  of  the  cicatrix  extends  from  the  centre 
towards  the  periphery.  In  large  scars  there  may  be  a  white  central  patch 
surrounded  by  a  dull  coppery-red  areola,  even  long  before  healing  is  com- 
pleted. In  all  cases  the  pigmentation  fades  slowly,  and  remains  longest 
in  the  areola.  Contraction  of  the  scar  near  joints  often  results  in  perma- 
nent deformity. 

The  prognosis  of  this  syphilide  is  never  very  good.  Still  a  fatal  result 
is  by  no  means  inevitable,  and  proper  treatment  is  in  many  cases  quite 
effective. 

The  diagnosis  from  serpiginous  lupus  and  serpiginous  chancroid  is  sel- 
dom difficult.  Lupus  usually  begins  in  early  life,  and  attacks  the  face. 
Its  ulcerations  are  less  definite  and  sharply  cut  than  those  of  the  syphilide. 
In  lupus,  red  tubercles  of  ulceration,  covered  by  crusts  of  light  yellow  or 
bluish-brown  are  mingled  with  the  cicatrices,  which  are  always  uneven 
and  fibrous.  The  history  of  the  case  may  add  to  the  certainty  of  diag- 
nosis. 

A  serpiginous  chancroid  usually  has  such  a  clear  history  that  no  mistake 
can  occur.  Its  locality,  its  extensively  undermined  edges,  its  fungoid 
surface,  and  its  erratic  course  are  also  sufficiently  diagnostic. 

In  opposition  to  the  view  of  some  that  this  eruption  is  not  syphilitic,  it 
is  only  necessary  to  say  tliat  it  always  begins  in  a  syphilitic  lesion,  that 
its  ulcers  and  crusts  have  features  similar  to  those  of  other  syphilitic 
lesions,  and,  finally,  that  its  cicatrices  are  typical  of  syphilis. 


558  syphilides. 

The  Pigmextaky  Sypiiilide. 

In  1853  Hardy  described  this  lesion,  which  has  since  been  the  subject 
of  monographs  by  Pillon,  Tanturri,  Fournier,  Drysdale,  Fox,  and  Atkin- 
son, but  its  nature  and  origin  are  still  questions  of  discussion. 

It  usually  appears  during  the  first  year  of  syphilis,  but  may  occur  as 
late  as  tlie  third  year.  It  is  composed  of  irregularly  round  or  oval  spots, 
with  ill-defined  or  jagged  margins,  of  a  brown,  cafe-au-lait  color,  which 
does  not  pale  under  pressure.  The  color  of  the  patches  may  be  so  faint  as 
to  require  a  strong  light  and  a  certain  position  for  their  detection,  and 
even  then  they  might  pass  for  spots  of  dirty  skin.  The  patches  vary  in 
diameter  from  one-eighth  of  an  inch  to  one  inch,  and  are  neither  elevated 
nor  scaly.  Tiiey  may  be  discrete  or  confluent,  in  some  instances  being 
sparsely  scattered,  and  in  others  occupying  a  surface  of  the  extent  of  one's 
hand,  and  presenting  very  different  appearances  under  the  two  conditions. 
In  the  former  the  spots  are  small,  and  separated  by  wide  intervals  of  un- 
altered skin.  In  but  one  instance  of  this  kind  have  we  found  each  spot 
surrounded  by  an  areola  of  pigment  of  a  deeper  color. 

AVhen  the  spots  are  more  numerous  they  })resent  the  peculiar  appearance 
aptly  compared  by  Fournier  to  a  "  network  of  lace  with  large  meshes." 
The  intervening  skin  seems  even  whiter  than  the  normal  skin,  an  appear- 
ance concerning  which  there  is  still  difference  of  opinion,  some  believing 
that  it  is  due  to  contrast  with  the  adjoining  brown  patches,  others  that 
there  really  is  a  decrease  or  an  absence  of  normal  pigment. 

According  to  the  latter  view,  there  is,  therefore,  at  the  same  time  a  de- 
crease of  pigment  in  certain  regions  and  an  increase  in  others.  The  latter 
process  we  regard  as  the  essential  one,  for  some  cases  are  seen,  in  which 
whitened  patches  cannot  be  detected,  and,  in  any  case,  they  are  much  less 
in  extent  than  the  pigmented  patches. 

Tanturri  is  said  to  have  found,  by  microscopic  examination,  as  much 
pigment  in  the  intermacular  skin  as  elsewhere,  but  the  probability  is  that 
the  results  of  this  observer  w^ere  obtained  in  cases  in  which  the  brown  spots 
only  were  present. 

On  the  other  hand,  it  is  the  opinion  of  Fox  that  this  eruption  is  a  local- 
ized loss  of  pigment  surrounded  by  regions  of  increased  pigmentation,  and 
he  considers  the  essential  lesion  to  be  the  oval  or  circular  s[)Ots  of  abnor- 
mal whiteness.  He  gives  a  case,  in  which  this  condition  followed  an  ery- 
thematous syphilide  upon  the  neck.  We  fully  recognize  the  fact  that 
decrease  of  pigment  may,  in  rare  instances,  be  observed  on  the  previous 
site  of  a  hypera^mic  syphilide,  but  we  believe  that  the  lesion  under  con- 
sideration is  spontaneous  in  its  origin,  and  not  a  sequel  of  hypera3mia. 

It  is  impossible  to  speak  positively  of  the  early  history  of  this  eruption, 
because  it  has  never  attracted  attention  until  fully  developed.  Its  evolution 
is  probably  gradual,  like  that  of  chloasma  and  leucoderma,  and  like  them 
it  is  a  chromatogenous  affection. 

The  most  frequent  seat  of  this  lesion   is  the  sides  of  the  neck,  where, 


MALIGNANT    PRECOCIOUS    SYPHILIDES.  559 

according  to  Fournier,  it  occurred  in  t'nenty-nine  out  of  thirty  cases.  It 
may  also  invade  the  chest,  abdomen,  and  even  tlie  lower  extremities.  It 
is  much  more  common  in  women  than  in  men,  and  is  especially  frequent 
in  those  of  a  light  complexion.  Its  course  is  extremely  chronic,  and  is 
uninfluenced  by  anti-syphilitic  treatment.  It  may  disappear,  perhaps  after 
months  or  even  years,  and  it  leaves  the  skin  apparently  unaltered.  It  is 
a  very  uncommon  disease  in  this  country. 

The  question  arises  whether  it  is  etiologically  related  to  syphilis,  or  is  a 
mere  accident  in  the  course  of  the  disease. 

In  favor  of  the  former  view,  we  have  the  opinion  of  six  observers,  who 
studied  the  lesion  independently.  Moreover  it  is  supported  by  the  well- 
known  fact  that  grave  systemic  dyscrasite,  among  which  we  must  include 
syphilis,  may  cause  chromatogenous  aifections. 

In  opposition  to  its  syphilitic  origin,  there  are  the  facts  that  it  differs  in 
appearance  from  every  other  specific  skin  lesion,  and  that  it  is  not  influ- 
enced by  anti-syphilitic  treatment.  In  our  opinion  there  is  a  remote  and 
obscure  connection  between  the  lesion  and  the  syphilitic  diathesis. 

For  a  long  time  the  affection  was  recognized  only  by  the  French  and 
Italian  observers,  whose  studies  in  syphilis  were  pursued  among  classes  of 
persons  more  predisposed  to  various  pigmentary  changes  than  are  the 
members  of  the  Anglo-Saxon  race.  Yet  it  is  distinctly  stated  by  them 
that  the  affection  was  met  with  in  persons  of  light  complexion,  and  it  is 
well  known  that  such  individuals  are  more  disposed  to  ephelides  and  pig- 
mentary changes  in  general. 

We  have  sought  for  this  eruption  in  nearly  all  the  cases  of  syphilis  under 
our  observation  for  the  last  eight  years,  and  have  discovered  only  six  well- 
marked  instances.  We  have  also  seen  a  similar  eruption  in  a  patient  with 
chronic  renal  disease.  Two  of  our  cases  w'ere  French  women,  and  the 
remaining  four  were  Anglo-Saxons  of  rather  dark  complexion. 

The  diagnosis  is  to  be  made  from  chloasma,  leucoderma,  and  tinea  ver- 
sicolor. From  the  first,  the  clinical  history  and  the  peculiar  appearance 
of  the  eruption  will  generally  distinguish  it.  In  leucoderma  tlie  white 
patches  have  distinct  brown  margins,  and  perhaps  a  background  of  similar 
color,  just  the  reverse  of  the  pigmentary  syphilide.  Tinea  versicolor 
rarely  exists  on  the  neck  exclusively,  but  is  usually  continuous  with  similar 
patches  on  the  chest.  It  is  darker  in  color,  slightly  elevated,  and  scaly, 
and  may  occasion  slight  itching.  Moreover  tlie  few  scales  from  the  syph- 
ilide are  composed  of  epidermis  only,  while  those  of  tinea  are  loaded  with 
the  spores  of  microsp  or  on  furfur. 

Malignant  ruECOCious  Sypiiilides. 

Under  this  title  French  authors  have  described  certain  syphilitic  erup- 
tions, which  have  a  malignant  ulcerative  character,  appear  early  in  syphilis 
and  are  accompanied  by  general  cachexia.  These  eruptions  vary  greatly 
in  exten+  and  duration.  In  some  cases  the  malignant  tendency  is  exhib- 
ited from  the  first,  while  in  others  it  attacks  a   previously  mild  eruption. 


560  SYPHILTDES. 

It  has  already  been  stated  that  certain  pustular  eruptions,  particularly  the 
impetigo-form  and  the  ecthyma-f'orm  syphilides,  and  much  less  frequently 
the  papular  rashes,  develop  this  character.  In  some  instances  this  peculiar 
feature  of  the  eruption  is  due  merely  to  the  excessively  debilitating  influ- 
ence of  the  syphilitic  poison  or  to  a  lowered  condition  of  nutrition.  Dr. 
Ory,  who  has  studied  the  etiology  of  the  malignant  syphilides,  concludes 
that  alcoholism  is  a  very  potent  cause,  but  that  any  adynamic  influence 
may  have  the  same  effect. 

These  syphilides  are  divided  into  three  classes  :  the  syphilide  pnro- 
crustucee  ttlcereuse,  the  syphilide  tnberculo-crustacee  iclcereuse,  and  the 
syphilide  tuberculo-ulcerante  yangreneuse. 

The  syphilide  puro-crxstacee  ulcereuse  is  a  pustular  rash  attended  by 
extensive  ulceration  and  formation  of  scabs.  It  begins  as  rounded  pustules 
grouped  or  irregularly  scattered,  which  soon  ulcerate  and  form  flat  or  con- 
ical greenish-black  crusts  which  may  blend  together.  The  ulcers  are  deep, 
with  sharply-cut,  undermined  edges  and  a  foul  base  secreting  a  fetid  pus. 
Such  an  eruption  appears  first  upon  the  face  or  scalp,  where  the  lesions  are 
often  in  groups;  then  it  invades  the  arms  and  may  even  extend  over  the 
entire  body,  successive  crops  of  pustules  being  developed  in  bad  cases. 
There  is  rarely  a  tendency  to  ringed  distribution,  but  sometimes  one  group 
of  pustules  is  increased  by  the  formation  at  its  periphery  of  new  pustules. 

Tiie  syphilide  tnberculo-crustacee  ulcereuse  begins  as  a  small,  red  tuber- 
cle, of  the  size  of  a  pea,  which  is  rapidly  converted  into  an  ulcer  with  a 
thick  crust.  The  subsequent  course  is  similar  to  that  of  the  previous 
variety,  except  that  the  destruction  of  tissue  is  often  much  greater.  This 
eruption  is  prone  to  appear  first  on  the  head  and  upper  extremities.  In 
some  cases  these  regions  only  are  attacked  ;  in  others  the  whole  body  is 
invaded.  Upon  the  face  the  ulcers  are  often  confluent  ;  upon  the  arms 
they  are  usually  scattered,  but  later  on  groups  may  be  formed  by  the  con- 
tinual accession  of  new  tubercles.  The  invasion  of  this  eruption,  like  that 
of  the  preceding  one,  may  be  rapid  or  slow.  Its  course  is  chronic,  some- 
times occupying  six  or  eight  months  or  even  a  year.  During  ulceration 
the  lesions  sometimes  cause  a  dull  pain,  and  are  at  all  times  a  source  of 
much  discomfort. 

The  syphilide  tuberculo-ulcerante  gangreneuse,  also  called  by  Auzias 
Tureiuie  carbuaculus  venereus,  one  of  the  most  formidable  manifestations 
of  syphilis,  is  hapi)ily  rare.  It  is  always  accompanied  by  cachexia,  and  if 
not  fatal,  always  leaves  a  condition  of  permanent  ill-health.  It  begins  as 
round  tubercles  of  a  dark-red  color,  slightly  elevated  and  deeply  seated  in 
the  skin,  which  attain  a  diameter  of  an  inch  or  more.  A  small  blackish 
slough  forms  in  the  centre  of  each  tubercle,  and  is  at  first  firmly  adherent ; 
it  extends  rapidly  and,  soon  becoming  loosened  by  the  secretions,  is  cast 
off  as  a  fetid,  cup-shaped  mass,  looking  something  like  an  inverted  rupia 
crust.  The  ulcer  thus  exposed  is  very  deep,  has  a  foul,  dark-brown  sur- 
face, with  hard,  everted  edges  and  secretes  a  fetid  ichor.  To  the  touch 
it  gives  the  impression  of  being  deeply  seated  and  indurated  like  a  typical 
initial  lesion  or  chancre.      Surrounding  each  tubercle  is  a  broad,  deep-red 


MALIGNANT    PRECOCIOUS    SYPHILIDES,  561 

areola.  Pliagedfena  may  occur  and  run  a  course  similar  to  that  of  phao-e- 
denic  gummous  ulcers.  From  time  to  time  brownish-green  crusts  form 
and  are  thrown  off.  In  favorable  cases  the  surface  of  the  ulcer  gradually 
assumes  a  more  healthy  appearance,  the  edges  become  softer  and  the  areola 
fades.  Granulations  appear,  and  true  pus  replaces  the  ichorous  discharge. 
The  healing  process  is  finally  completed,  leaving  a  depressed  cicatrix  of  a 
coppery-red  color,  which  gradually  fades  from  the  centre  towards  the 
periphery  of  the  cicatrix.  When  fully  formed  the  cicatrix  is  of  a  dead- 
white  color,  flexible  and  thin  like  parchment. 

The  invasion  of  this  syphilide  is  generally  rapid,  but  its  subsequent 
course  is  slow.  Usually  tubercles  are  developed  in  region  after  region, 
followed,  perhaps,  by  additional  crops.  They  are  irregularly  scattered, 
with  no  tendency  to  a  ringed  form.  The  face,  the  extremities,  the  shoul- 
ders and  buttocks,  are  its  favorite  seats.  The  eruption  may  persist  for 
several  months  or  even  years,  altliough  in  the  most  malignant  cases  it  runs 
a  course  called  by  French  authors  "  galloping.'^  In  such  cases  the  inva- 
sion is  very  rapid  and  the  result  is  generally  fatal. 

At  or  shortly  before  the  appearance  of  these  precocious  syphilides,  the 
patients  complain  of  weakness,  and  appear  pale  and  sallow.  They  often 
suffer  from  fugitive  pains  and  neuralgias  and  from  a  general  sense  of  dis- 
comfort. They  have  no  appetite  and  become  emaciated.  At  the  same 
time  some  febrile  reaction  may  be  noticed.  If  not  checked,  this  adynamic 
condition  increases  pari  passu  with  the  eruption  ;  the  patient  falls  into  a 
typhoid  state  and  dies.  Possibly  some  intercurrent  visceral  lesion,  of  the 
lungs  or  of  the  nervous  system,  hastens  the  fatal  result.  In  some  cases, 
no  definite  visceral  affection  can  be  detected,  and  the  patient  dies  of  ma- 
rasmus. Very  often  lesions  peculiar  to  a  later  period,  such  as  nodes, 
neci'oses,  sarcocele,  etc.,  appear  with  this  malign  eruption.  In  other  cases, 
although  the  syphilide  is  essentially  malignant,  health  gradually  returns 
after  a  prolonged  period  of  impaired  nutrition  and  extreme  debility. 

The  prognosis  of  these  syphilides  is  always  grave,  since  they  indicate  a 
most  intense  and  active  form  of  syphilis.  The  health  of  the  patient  pre- 
vious to  infection,  his  habits,  the  extent  and  character  of  the  eruption  and 
the  degree  of  cachexia  must  all  be  considered.  The  course  of  the  lesions 
and  the  influence  of  treatment  must  be  watched.  Death  almost  always 
results  from  the  intercurrence  of  some  pulmonary  or  nervous  affection. 

As  regards  treatment,  every  efl"ort  should  be  made  to  improve  nutrition. 
Much  can  be  done  towards  checking  the  course  of  the  eruption  by  the 
employment  of  local  measures.  Careful  dressing  of  the  ulcers,  their  tho- 
rough disinfection,  and  the  early  removal  of  secretions,  not  only  add  to  the 
comfort  of  the  patient  but  promote  healing.  In  spite  of  every  precaution, 
indelible  cicatrices  are  generally  left.  Internal  treatment  must  also  be 
employed.  The  guarded  use  of  mercury,  preferably  by  inunction,  with 
iodide  of  potassium,  sodium,  or  ammonium,  internally,  is  indicated.  Opium 
is  often  found  [)articularly  useful  in  these  cases,  by  calming  the  restless- 
ness of  ihe  patient,  and  (piieting  the  pain  of  the  ulcers.  In  a  recent  case 
of  our  own,  in  wliich  the  malignant  syphilide  was  accompanied  by  profound 
36 


562  SYPHILIDES. 

cachexia,  by  severe  and  persistent  rheumatoid  pains,  and  by  double  iritis, 
this  dejdorable  condition  was,  in  less  than  a  week,  markedly  improved  by 
the  addition  of  a  little  opium  to  the  mixed  treatment,  combined  with 
tonics.  We  may  sometimes  resort  to  mercurial  vapor  baths  with  iodide  of 
potassium  or  sodium,  combined  with  bitter  tonics,  internally,  beginning  with 
ten-  to  fifteen-grain  doses  three  or  four  times  a  day,  and  gradually  increased 
by  two  or  three  grains  daily.  Mercury  given  in  this  way  is  supposed  to 
have  a  beneficial  local  as  well  as  general  effect.  The  condition  of  the 
stomach  demands  that  the  most  digestible  and  nutritious  food  be  taken,  if 
possible  in  small  quantity  and  at  frequent  intervals.  Stimulants,  prefer- 
ably good  port  wine  or  brandy,  must  be  given  regularly.  Such  treatment 
as  the  above  is  suitable  Avhen  the  patient  is  still  able  to  move  about.  In 
a  typhoid  condition,  treatment  applicable  to  the  adynamic  fever  is  called 
for,  together  with  the  careful  use  of  the  iodides.  The  crusts  of  the  ulcers 
should  be  removed  after  softening  them  with  simple  ointment  or  cosmoline, 
to  which  a  few  drops  of  carbolic  acid  have  been  added.  AVhen  they  cover 
the  whole  body,  an  alkaline  bath  may  be  required  for  this  purpose.  The 
exposed  surface  of  the  ulcers  should  be  touched  with  carbolic  acid,  applied 
with  cotton  wool  or  a  brush.  Its  action  is  twofold ;  it  allays  pain  and 
destroys  the  diseased  tissue.  The  formation  of  scabs  may  be  prevented 
by  the  application  of  an  ointment  or  the  water  dressing.  An  ointment 
composed  of  one  part  of  mercurial  ointment,  one  part  of  Balsam  of  Peru, 
and  six  parts  of  Cosmoline,  applied  on  lint  and  frequently  renewed,  is  of 
great  service.  Simple  lead  water  or  a  solution  of  the  Bichloride  of  Mei*- 
cury  (gr.  xij  (0.80)  to  water  gxv  (4G0.00)  and  glycerin  sj  (40.00)  )  is 
to  be  preferred,  when  there  is  much  hyperaemia.  The  latter  has  a  special 
detergent  and  stimulating  effect.  As  the  case  progresses,  such  superficially 
destructive  stimulants  as  nitrate  of  silver  in  strong  solution,  or  fluid  car- 
bolic acid,  may  be  indicated.  The  ulceration  is  sometimes  arrested  and 
repair  hastened  by  prolonged  immersion  of  the  body  in  hot  water.  These 
hot  baths  may  be  rendered  more  efficacious  by  the  addition  of  two  or  three 
drachms  of  corrosive  sublimate  to  each  thirty  gallons  of  water.  Care 
must  be  exercised  as  regards  their  frequency  and  duration.  The  mercu- 
rial vapor  bath  is  often  of  benefit  after  removal  of  all  the  crusts,  but  its 
effect  must  be  carefully  watched. 

By  way  of  prophylaxis,  when  the  eruption  shows  a  tendency  to  extend, 
all  possible  sources  of  irritation  of  the  skin  must  be  removed. 

Spontaneous  Gangrene  in  the  Course  of  Syphilis. 

Very  little  is  known  of  this  possible  consequence  or  complication  of 
syphilis.  Prof.  Podres,  of  Crakow,  has  reported  the  case  of  a  man,  forty- 
five  years  old,  who,  six  years  after  infection,  began  to  have  pain  in  his 
legs,  which  became  very  anaemic,  sensitive  to  cold,  ccdematous  and,  finally, 
gangrenous.  This  condition  necessitated  amputation  :  first  of  the  toes,  then 
of  the  foot,  and  finally  of  the  thigh.  Microscopic  examination  showed 
inflammation  of  the  external   tunic  of  the  arteries,  defeneration  of  their 


LOCAL    TREATMENT    OF    SYPHILIDES.  563 

endotlieliuni,  with  tl)ickeniiig  of  their  walls  and  obliteration  of  their  calibre. 
There  was  also  atrophy  of  the  cutaneous  glands  and  nerves.  All  of  these 
changes  were  attributed  by  Podres  to  syphilis.^ 

Local  Treatment  of  the  Syphilides. 

The  syphilides  always  require  thorough  constitutional  treatment,  and  this, 
as  a  general  rule,  should  be  mercurial.  Those  of  the  secondary  statue  re- 
quire mercury  alone,  while  those  of  a  later  stage  are  best  treated  by 
mercury  combined  with  the  iodide  of  potassium.  The  opinion  largely 
prevails  that  gummata  of  the  subcutaneous  tissues,  being  tertiary  lesions, 
demand  only  the  potassium  salt,  but  we  regard  this  idea  as  erroneous. 
Under  the  iodide  alone  we  have  often  found  the  result  slow  and  unsatis- 
factory, while  a  combination  of  the  two  remedies  has  almost  invariably 
led  to  a  speedy  and  beneficial  action.  In  spite,  however,  of  the  best 
directed  internal  medication,  some  of  the  syphilides  urgently  require  local 
treatment. 

The  exanthematous  syphilides  are  generally  ephemeral,  and  do  well 
under  internal  treatment  alone.  In  some  cases,  however,  their  persistence 
upon  exposed  parts,  as  the  face,  the  hands,  and  particularly  about  the 
wrists,  demands  something  more  for  their  removal.  For  this  purpose,  the 
best  application  is  an  ointment  or  lotion  containing  a  mercurial  salt: 

I^.     Hydrarg.  Oxid.  Rubri,  vel 

Ammoniati  gr.  x-xx       .     .     ,  65 — 1  30 

Cerati  SimpL,  vel  Ung.  Aq. 

Rosse  ^j 30| 

M. 

A  small  quantity  of  this  ointment  is  to  be  rubbed  in  twice  a  day,  and 
a  liberal  quantity  be  left  on  over-night.  The  following  may  also  be  rec- 
ommended : — 

I^.     Ung.  Hydrarg.  §ij 81 

Cerati  Simplicis,  vel  Ung.  Aq.  Rosse  §j      30| 
M. 

The  five  or  ten  per  cent,  oleate  of  mercury  is  also  generally  useful  in 
the  erythematous  and  papular  eruptions.  When  using  any  of  the  above, 
brisk  friction  of  the  parts  should  be  employed  within  the  bounds  of  avoid- 
ing dermal  inflammation.  In  urgent  cases,  the  ointment  may  be  spread 
on  lint  and  kept  constantly  applied  to  the  spots. 

Lotions  are  sometimes  of  very  decided  benefit,  especially  in  cases  of 
deep  coppery  pigmentation  so  often  left  upon. the  foreliead,  which  is  very 
annoying  to  patients  and  is  but  slightly  influenced  by  internal  medication. 


I^.     Hydrarg.  Chloridi  Corrosivi  gr.  iv 

Ammonii  Chloridi  gr.  x 

Aq.  Colognieiisis  ^ss 15 

Aquam  ad  §iv 125 

M. 


>  Centralbl.  f.  Chir.,  Leipz,  No.  33,  1876. 


564  SYPHILIDES. 

This  should  be  freely  sponged  on  the  parts,  or,  in  obstinate  cases,  be 
constantly  applied  by  a  piece  of  lint  saturated  with  it.  When  the  pig- 
mentation is  scattered  generally  over  the  body,  or  when  the  erythematous 
eruption  is  very  chronic,  as  also  in  its  relapsing  form,  mercurial  vapor 
baths  are  our  most  efficient  remedy.  If  these  are  unattainable,  baths 
of  corrosive  sublimate  (5j-iv  to  30  gallons  of  water,  with  the  addition  of  ^ij 
of  the  chloride  of  ammonium  to  facilitate  solution)  will  answer  the  purpose. 

The  pa[)ular  sypliilidcs  are,  as  a  rule,  amenable  to  internal  treatment, 
but  in  some  cases  in  which  this  has  been  neglected,  and  in  others  of  the 
small  miliary  form,  they  are  often  annoyinglj  persistent.  If  the  eruption 
be  confined  to  small  areas,  the  ointments  and  lotions  just  mentioned  will 
be  all  sufficient.  If  large  surfaces  are  involved,  we  may  employ  tliese 
ointments  in  the  form  of  inunction,  but,  in  general,  baths  of  various  kinds 
are  desirable,  and  should  be  repeated  as  often  as  may  be  necessary.  In 
some  cases,  we  have  derived  decided  benefit  from  sulphur  baths,  and,  again, 
from  alkaline  baths  (one  pound  of  the  bicarbonate  or  the  borate  of  sodium 
to  thirty  gallons  of  hot  water).  Brisk  friction  with  one  of  the  above 
ointments  will  greatly  hasten  the  result. 

The  most  rebellious  forms  of  the  early  syphilides  are  those  of  the  palms 
and  soles  iii  their  chronic  scaly  stage.  These  will  persist  for  long  periods 
unless  local  be  added  to  internal  treatment.  The  applications  should  be 
varied  according  to  the  stage  of  the  eruption,  and  it  is  desirable  to  attend 
to  them  from  their  very  commencement.  When  treated  early  by  daily 
inunction  of  a  salve  composed  of  equal  parts  of  strong  mercurial  ointment 
and  cosmoline,  the  papules  will  rapidly  disappear ;  the  cure  is  hastened 
by  the  continuous  application  of  the  same,  the  hands  being  covered  with 
gloves  constantly  worn.  This  ointment  will  sulfice  for  cases  in  the  true 
papular  stage,  but  is  not  sufficient  when  the  papules  have  become  scaly 
and  the  skin  thickened.  We  should  then  adopt  the  treatment  of  simple 
psoriasis,  and  immerse  the  parts  in  hot  water,  to  which  an  alkali  has  been 
added  in  the  proportion  of  one  or  two  ounces  to  two  quarts.  The  addition 
of  a  handful  of  bran  is  excellent  when  painful  fissures  are  present.  This 
should  be  repeated  every  day  or  two,  and  the  scales  be  removed  when 
they  are  softened.     After  drying  the  parts,  they  should  be  anointed  with 

R.     Ung.  Hydrarg.  5ij 8 

01.  Rusci,  vel  Betuhe  Alb., 

vel  Olei  Cadini  3ss-j      ...       2 

Gelati  Petrolei  §j' 30 

M. 

R.     Hydrarg.  Ammoniati,  vel  Hydrarg. 

Oxid.  Rubri  gr.  x-xx     .     .     .  65—1  30 

Olei  Rnsci,  vel  Cadini  3ss-§j      .       2  4 

Ung.  Simplicis  §j 30 

M. 

'  Vaseline  and  CoBmoline  (essentially  tlie  same,  but  the  latter  more  consistent) 
have  received  no  officinal  name,  but  the  suggestion  of  their  manufacturer,  Mr. 
Chesebrough,  "Gelatuni  Petrolei,"  is  good. 


LOCAL    TREATMENT    OP    SYPHILIDES.  565 

a  mild  mercurial  ointment,  to  which  a  stimulant  tarry  preparation  is  a 
valuable  addition  in  many  cases. 

These  ointments  should  be  thoroughly  rubbed  in  and  applied  contin- 
uously on  lint,  retained  by  gloves.  In  some  cases,  gloves  of  India-rubber 
are  best  worn  during  the  day,  the  ointment  being  applied  two  or  three 
times.  Cases  occur  in  which  the  thickening  is  so  extensive  and  severe, 
that  we  are  obliged  to  resort  to  still  stronger  solutions,  as  of  potassa  fusa 
or  pure  caustic  soda,  in  the  proportion  of  from  one-half  to  even  two  drachms 
to  the  ounce  of  water.  After  soaking  the  bands  or  feet  in  warm  water, 
they  should  be  briskly  rubbed  with  a  small  pad  of  flannel  tied  to  the  end 
of  a  stick  and  saturated  with  one  of  these  solutions,  paying  particular  at- 
tention to  those  parts  where  the  accumulation  of  scales  is  greatest.  The 
duration  of  the  rubbing  is  to  be  determined  by  the  sensations  of  the  patient 
and  the  effect  produced,  but  it  is  desirable  to  avoid  producing  a  very  raw 
surface  or  too  acute  inflammation,  the  object  being  merely  the  removal 
of  effete  epidermal  scales.  The  parts  may  subsequently  be  so  tender  as  to 
require  the  use  of  a  water  dressing  for  a  few  hours,  but,  as  soon  as  possi- 
ble, one  of  the  ointments  above  mentioned  should  be  applied.  By  the 
judicious  use  of  this  treatment,  continued  if  necessary  for  a  considerable 
time,  cases  of  great  severity  may  be  cured. 

We  have  omitted  to  mention  that  in  some  cases  of  syphilitic  psoriasis  of 
the  palms,  the  patches  are  in  an  inflamed  condition,  which  must  first  be 
relieved.  For  tliis  purpose  we  envelop  the  parts  in  emplastrum  plumbi 
spread  on  strips  of  linen,  and  later  on  use  the  following  ointment : — 

5.     Emplast.  Plumbi  ^vj 24 

Ung.  Hydrarg.  5ij 8 

01.  Betulae  Alb.,  vel  01.  Cadini  3]   .     .  4 

M. 

Pustules  upon  the  scalp  are  commonly  so  small  and  ephemeral  as  to  re- 
quire no  special  treatment,  but  in  some  cases  they  are  so  cojnous  and 
persistent  as  to  render  local  applications  desirable. 

Shampooing  with  an  alkaline  lotion,  careful  removal  of  the  scabs,  and 
the  application  of  the  following  ointment,  is  all  that  is  necessary. 

I^.     Unguent.  Hydrarg,  Nitratis  ^ij        .     .       8| 

Gelati  Petrolei  §j 3U| 

M. 

Pustules  of  the  malignant  precocious  syphilides,  wherever  situated,  often 
exhibit  a  destructive  tendency.  The  removal  of  tiie  scabs  is  the  first 
necessity,  and  to  this  end  one  or  more  immersions  in  alkaline  baths  are 
generally  sufficient  to  soften  them  so  that  they  can  b<;  taken  of!'  without 
difficulty.  If  the  exposed  ulcers  are  very  i)ainful,  they  may  be  touched 
once  or  twice  with  carbolic  acid  diluted  in  water,  about  one  part  to  live. 
This  application  not  only  stimulates  the  sores  but  relieves  the  pain.  If 
the  ulcers  are  numerous,  the  subsequent  dressings  are  somewhat  tedious. 
Tliey  should  be  powdered  over  with  iodoform,  or  this  may  be  used  in 
etherial  solution  or  in  a  salve,  or,  again,  these  and  other  open  ulcers  may 
be  covefcjd  with  the  Emplastrum  de  Vigo  cum  Mercurio  spread  on  lint  or 
soft  leather. 


566  SYTHILIDES. 

Serpiginous  ulcerations  may  be  treated  in  the  same  way  as  the  above, 
or,  after  the  removal  of  the  scabs,  a  stimulating  lotion  as  the  following, 
may  be  kept  constantly  applied. 

;^.     Hydrarg.  Chloridi  Corros.  3ss    ....  2 

Acidi  Carbolici  gj 4 

Glyceriiiae  §j 40 

Aquae  §xv 460 

M. 

Profuse  granulations  may  spring  up  in  the  ulcerated  ring  and  require 
pencilling  with  the  stick  nitrate  of  silver.  Besides  the  lotion  just  men- 
tioned, the  following  ointment  is  often  very  beneficial. 

I^.     Ung.  Hydrarg.  Nitratis  ^^ij 8 

Bals.  Peruv.  gss 6 

Gelati  Petrolei  §j 30 

M. 

This  treatment  is  applicable  to  almost  any  form  of  syphilitic  ulcerations, 
and  to  rupia  especially.  The  vegetating  or  hypertrophic  syphilides  should 
be  treated  by  repeated  slight  cauterizations  with  carbolic  acid  (one  or  two 
])arts  to  six  of  water),  or  with  a  solution  of  nitrate  of  silver  (5j  to  Jj). 
They  may  also  be  benefited  by  the  various  mercurial  baths. 

The  treatment  of  gummata  varies  according  to  their  condition.  In  the 
stage  of  infiltration  before  ulceration  has  occurred,  vigorous  internal  medi- 
cation, combined  with  tlie  constant  application  of  equal  parts  of  mercurial 
and  oxide  of  zinc  ointments,  may  cause  their  absorption.  When  they 
exhibit  fluctuation  or  point  like  a  furuncle,  it  may  become  necessary  to 
incise  them,  but  it  is  well  not  to  be  precipitate,  as  they  will  sometimes  be 
absorbed  even  in  this  stage  ;  and  we  then  escape  any  solution  of  continuity 
in  the  skin.  Gummatous  ulcers  vary  so  much  in  depth  and  in  the  amount 
of  morbid  tissue  at  their  base,  that  no  absolute  rule  can  be  laid  down  as  to 
their  local  treatment.  When  we  find  a  foul,  indolent,  necrotic  base, 
thorough  cauterization  should  be  made  with  a  strong  solution  of  caustic 
potash  or  soda  (3J-ij  to  §j  of  water).  Healing  will  not  take  place  until 
the  gummy  tissue  is  destroyed,  hence  it  is  necessary  to  cauterize  until  a 
healthy,  granular  base  is  seen.  After  the  cauterization,  a  water  dressing 
may  be  applied  until  all  infiammatory  action  has  passed  oiF,  when  the 
ulcer  may  be  dusted  with  iodoform,  while  to  the  reddened  areola  the  mer- 
curial and  zinc  ointment,  already  mentioned,  may.  be  applied.  As  the 
base  of  the  ulcer  becomes  more  superficial,  the  necessity  of  cauterization 
ceases,  and  should  exuberant  granulations  spring  up,  as  is  often  the  case, 
they  may  be  touched  with  nitrate  of  silver. 

The  latest  application  for  ulcerating  syphilides,  recommended  by  Guil- 
laumet,^  is  the  bisulphate  of  carbon.  Other  than  a  slightly  stimulant 
action,  it  possesses  no  medicinal  qualities,  and  its  use  is  much  restricted 
by  its  disgusting  smell. 

•  J.  de  tlierap.,  Paris,  No.  3,  1875. 


CUTANEOUS    HEMORRHAGE    IN    SYPHILIS.  567 


CHAPTER    XII. 
CUTANEOUS    HEMORRHAGE    IN    SYPHILIS. 

Any  of  the  secondary  eruptions  of  syphilis  may  be  accompanied  by 
hemorrhagic  effusion,  either  around  or  into  the  substance  of  the  lesion. 
It  may  occur  on  the  lower  extremities  of  those  whose  general  health  is 
unimpaired  and  is  then  not  of  serious  import ;  or  it  may  occur  on  various 
other  portions  of  the  body  of  broken  down  and  scorbutic  persons.  In  all 
of  these  cases  the  effusion  is  secondary  to  the  specific  process,  spontaneous 
transudation  of  blood  into  the  skin  of  syphilitics  being  quite  a  rare  occur- 
rence. A  case  of  much  interest  has  been  reported  by  Balz,'  as  follows : 
a  man,  aged  twenty-five,  healthy  but  having  had  typhus  fever,  when  syphi- 
litic one  year,  suddenly  and  without  premonition  became  covered  with  a 
blood-red  exanthem.  This  was  composed  of  discrete  and  confluent  spots, 
varying  in  size  from  a  millet  seed  to  a  silver  dollar.  The  blood-red  color 
rapidly  faded  and  left  slightly  scaly,  reddish-  and  greenish-yellow  patches 
similar  to  those  seen  in  scorbutus.  Coincidently  he  had  swelling  of  the 
joints  of  the  little  finger,  wrist,  right  elbow,  and  both  feet,  due  to  ultra- 
and  peri-articular  hemorrhagic  effusion.  The  cheeks  and  eyelids  were 
swollen,  but  the  gums  were  normal.  The  urine  did  not  contain  blood. 
Four  days  later  a  new  eruptioTi  occurred  simultaneously  with  an  attack 
of  pleuro-pneumonia.  For  the  latter  an  ice-bag  was  a|)plied  to  the  chest, 
resulting  in  the  development  of  a  large  patch  of  effused  blood,  which  slowly 
subsided,  the  skin  being  (Edematous  and  sensitive.  A  second  application 
of  the  ice-bag  produced  a  similar  result.  Under  the  use  of  iodide  of  potash 
the  patient  was  cured  in  four  weeks,  Biilz  thinks  that  syi)hilis  induced 
in  this  case  a  hemorrhagic  diatiiesis.  He  also  speaks  of  another  case  of  a 
healthy  man,  who,  a  short  time  after  syphilitic  infection,  was  attacked  by 
a  general  hemorrhagic  eruption,  with  epistaxis,  bloody  urine,  bloody  stools, 
and  febrile  reaction.  Several  days  later  a  papular  sy[)hilide  api)eared 
among  the  patches  of  effusion,  and  on  the  tenth  day  the  man  died. 
Whether  this  hemorrhagic  condition  was  a  mere  coincidence  or  was  etio- 
logically  related  to  syphilis  it  is  impossible  to  say. 

We  have  also  seen  a  case  of  hemorrhagic  effusion  occurring  late  in 
syphilis.  The  patient,  a  man  forty-six  years  of  age,  had  suflered  severely 
from  various  lesions,  and  of  late  with  extensive  ulcerating  gummata. 
Twelve  years  after  infection,  being  in  a  cachectic  state,  he  was  attacked 

Ueber  haemorrhagischo  Syphilis.     Arch.  d.  Hoilk.,  Fob.  1875. 


568  CUTANEOUS    HEMORRHAGE    IN    SYPHILIS. 

by  a  general  but  not  copious  eruption  of  bulla;.  These  when  first  seen 
contained  sero-i)us,  but  soon  became  of  a  deep  red  color,  and  around  them 
a  wide  areola  of  effused  blood  appeared,  with  large,  slightly  raised  hemor- 
rhagic patches  between  them.  The  bullae  became  large,  foul  ulcers  ;  the 
eftused  patches  grew  larger,  and  some  coalesced.  The  patient  finally 
passed  into  a  lyplioid  condition  and  died.  In  this  instance  the  hemor- 
rhagic condition  or  diathesis  was  probably  caused  by  syphilis. 


ECZEMA    OP    THE    SCROTUM    AND    PENIS.  569 


CHAPTER  XIII. 

CERTAIN   SIMPLE   CUTANEOUS   AFFECTIONS   OF 
THE   GENITALS. 

Under  this  head  are  included  some  of  the  more  common  diseases  of  the 
skin,  and  especially  those  affecting  the  genital  organs,  Avhich  are  some- 
times regarded  by  inexperienced  persons  as  of  venereal  oi'igin. 

Eczema  of  the  Scrotum  and  Penis. 

The  male  genitals,  especially  the  scrotum,  are  frequently  the  seat  of 
eczema,  either  limited  to  these  regions,  or  constituting  a  part  of  a  general 
eruption. 

This  begins  as  a  slight  redness  of  the  surface,  attended  by  pruritus.  The 
scrotal  surface  becomes  thickened  and  cedematous,  the  normal  furrows  being 
much  deepened.  In  most  cases  the  lesion  is  a  dry,  scaling  eczema,  but 
it  is  sometimes  of  the  moist  variety.  The  affection  is  very  persistent,  and 
is  accompanied  by  itching  and  a  burning  heat,  often  almost  intolerable. 
The  suffering  may  be  increased  by  the  formation  of  deep  fissures.  In  many 
cases  the  lesion  spreads  to  the  thighs  and  perinceum. 

When  the  penis  is  attacked,  its  integument  becomes  much  thickened 
and  phimosis  may  be  produced. 

This  affection  is  rarely  seen  before  puberty,  occurring  usually  in  young 
and  middle-aged  men.     Relapses  are  often  observed. 

The  etiology  of  this,  like  other  varieties  of  eczema,  is  not  clear.  Pro- 
bably in  many  cases  local  irritation  is  the  starting  point  of  the  affection, 
while  in  some  the  rheumatic  and  gouty  diatheses  may  act  as  predisposing 
causes. 

Treatment. — The  treatment  of  eczema  of  the  scrotum  is  often  very  un- 
satisfactory. In  its  early  stages,  when  there  is  much  hyperaimia,  the  best 
application  is  diachylon  ointment,  to  which  a  little  powdered  camphor  may 
be  added.  The  inflamed  surface  should  be  covered  with  pieces  of  lint 
smeared  with  the  ointment,  and  the  parts  be  then  placed  in  a  suspensory. 
The  acute  oedema  of  the  early  stage  is  often  benefited  by  immersion  of  the 
parts  once  or  twice  daily  in  very  warm  bran-water,  followed  by  the  appli- 
cation of  the  ointment.  As  the  case  becomes  chronic  and  the  infiltration 
more  dense,  some  stimulating  agent,  such  as  the  oil  of  cade,  or  the  oil  of 
white  birch,  should  be  added  to  the  ointment.  Half  a  drachm  of  the  oil 
may  be- combined  witli  an  oinice  of  diacliylon  ointment,  and  the  mixture 
should  be  used  when  fresh,  since  it  readily  decomposes.      The  proportion 


570  CUTANEOUS    AFFECTFONS    OF    THE    GENITALS. 

of  the  oil  may  be  increased  according  to  the  toleration  of  the  parts.  It  is 
rarely  necessary  to  add  more  than  two  drachms  to  each  ounce.  Wliile 
treatment  is  thus  followed,  the  patient  should,  if  possible,  avoid  active 
exercise. 

In  some  chronic  cases  the  thickening  is  so  dense  and  the  pruritus  so 
severe,  that  more  active  stimulation  is  required.  We  then  resort  to  a 
strong  solution  of  caustic  potassa  or  soda,  in  the  proportion  of  from  half  a 
drachm  to  two  drachms  to  the  ounce  of  water.  This  should  be  carefully 
ai)plied  with  a  sponge  or  pad  of  flannel  for  five  or  ten  minutes.  Its  imme- 
diate effect  is  to  produce  much  redness  and  swelling,  with  more  or  less 
superficial  excoriation.  From  the  excoriated  surface  small  drops  of  viscid 
secretion  slowly  exude  for  an  hour  or  two.  Water-dressing  maybe  needed 
to  control  the  reaction.  Finally  tlie  parts  may  be  enveloped  in  strips  of 
lint  smeared  with  the  ointment,  which  should  be  renewed  twice  daily. 
The  reapplication  of  the  caustic  solutions  may  be  indicated.  In  occasional 
instances  we  have  used  vesicating  collodion,  instead  of  the  caustics,  with 
similar  results  and  with  decided  relief  of  the  intense  pruritus. 

Tinea  Circinata  Inguinalis. 

Under  the  titles,  herpes  inguinalis  (Baerensprung)  and  eczema  margi- 
natum (Hebra)  has  been  described  a  form  of  ring-worm  occurring  about 
the  genitals,  particularly  of  males,  which  sometimes  resembles  eczema. 

The  eruption  begins  as  a  small  round  spot  on  the  inside  of  the  thigh, 
vi'liere  it  is  in  contact  with  the  scrotum,  or  upon  the  pubic  region.  It  is 
rarely  seen  by  the  surgeon  in  its  early  stage.  If  uncomplicated,  we  find 
a  narrow  ring,  not  very  much  elevated,  often  scaly,  and  composed  in  part 
of  vesicles.  Its  color  is  darker  than  that  of  ringworm,  as  seen  on  the  neck 
and  on  other  exposed  regions.  The  inclosed  area  of  skin  is  sometimes 
almost  normal ;  it  may  be  red  and  scaly,  and  the  hairs  growing  from  the 
part  are  broken  and  lack  their  normal  lustre,  as  though  their  nutritioji 
were  impaired.  In  some  cases  the  hairs  seem  to  be  unaffected.  The 
rings  formed  by  the  eruption  tend  to  spread  down  the  thighs,  over  the 
perinaeum  to  the  buttocks,  and  up  the  hypogastric  region  to  the  umbilicus. 
Not  infrequently  the  affection  appears  at  about  the  same  time  in  the  axillse 
and  from  there  extends  in  the  form  of  rings. 

In  the  chronic  cases,  in  which  a  large  extent  of  surface  is  involved  by 
the  eruption,  the  skin  inclosed  by  the  rings  undergoes  various  changes. 
Sometimes  new  rings  appear  within  the  larger  ones,  so  tliat  we  may  find 
the  thighs,  buttocks,  and  abdomen  covered  with  large  and  small  circles 
and  segments  of  circles,  or  simply  by  wavy  and  irregular  lines.  This 
condition  may  continue  for  months  or  even  years,  or  the  lesion  may  assume 
an  eczematous  character  as  it  extends  at  the  periphery.  The  affected  skin 
becomes  thickened  and  inflamed,  and  papules,  pustules,  and  perhaps 
numerous  scales  may  form  upon  it.  Owing  to  greater  cleanliness  and 
early  treatment  we  do  not  frequently  see  this  aggravated  form  of  ringworm, 
but  in  Austria,  according  to  Hebra,  it  is  quite  common  among  shoemakers 


SCABIES    OF    THE    GENITAL    ORGANS.  511 

and  cavalry  men.  English  authors  state  that  it  is  often  seen  in  patients 
returning  from  China,  India,  and  other  Eastern  countries.  The  course  of 
this  aff'ection  is  quite  chronic ;  while  it  yields  readily  in  its  early  stages,  it 
is  very  rebellious  to  treatment  at  a  later  period,  and  is  prone  to  recur. 

The  most  reliable  remedy  is  sulphurous  acid,  which  should  be  thoroughly 
applied  once  or  twice  a  day  after  cleansing  the  parts  with  soap  and  water. 
In  many  cases  simply  painting  the  affected  region  with  tincture  of  iodine 
is  sufficient.  German  authorities  speak  in  high  terms  of  Wilkinson's 
ointment,  which  is  modified  by  Hebra  as  follows: — 

^.     Flor.  Sulph., 

01.  Fagi.,  aa  giij 90 

Cretfe  Albc-B  §ij 60 

Saponis  Viridis 

Axungi£e  Porci,  aa  §viij 240 

This  ointment  should  be  well  rubbed  in,  and,  instead  of  washing  it  off, 
the  anointed  surface  may  be  dusted  with  powdered  starch.  Another  oint- 
ment we  have  used  with  benefit  in  these  cases  is  made  as  follows : — 

I^.     Hydrarg.  Precip.  Alb.  gv.  xlv   ....  31 

Potass.  Sub-carb.  5iss 6 

01.  Cadini  Piii] 12 

Uiig.  Simplicis,  | 

Ung.  Petrolei  aa  §j 30| 

M. 

The  subcarbonate  of  potash  should  be  dissolved  in  a  few  drops  of  water 
and  then  the  other  ingredients  may  be  added.  When  there  is  much 
hyperemia  and  eczema  it  is  necessary  to  use  soothing  and  astringent  appli- 
cations to  reduce  tlie  inflammation,  before  attacking  the  parasite  wliich  is 
the  cause  of  the  affection.  It  is  important  to  guard  against  reinfection, 
which  is  liable  to  occur  from  spores  lodging  in  the  meslies  of  the  under- 
clothing. 

This  affection  occurs  much  more  frequently  in  males  than  in  females 
and  is  usually  observed  in  young  and  middle-aged  persons.  It  is  caused 
by  the  parasite  known  as  the  tricophyton  tonsurans. 

Scabies  of  the  Genital  Organs. 

Scabies,  or  itch,  may  be  limited  to  the  genitals,  or  it  may  involve  these 
organs  at  the  same  time  with  other  regions  of  the  body.  It  occurs  rather 
more  frequently  upon  the  penis  than  upon  the  female  genitals,  and  is 
sometimes  very  persistent.  Upon  the  mucous  more  commonly  than  upon 
the  tegumentary  covering  of  the  penis  we  find  slightly  elevated  papules 
and  moderately  distended  pustules.  Sometimes  we  also  find  the  maiks  of 
scratching  and  patches  of  hyperjEmia.  In  some  cases  very  careful  ex- 
amination will  reveal  the  furrow  of  the  acarus,  as  a  small  whitish  linear 
elevation,  varying  in  length  from  one-eighth  to  one-half  an  inch.  These 
furrows  or  cuniculi  deiinitely  prove  the  presence  of  the  itchmite.  They 
are  sometimes,  however,  not  found  here  as  in  other  localities.     In   bad 


572  CUTANEOUS    AFFECTIONS    OF    THE    GENITALS. 

cases  an  eczematous  condition  of  the  penis  is  produced  by  the  excessive 
irritation. 

This  affection  tends  to  remain  in  a  chronic  condition  ;  papules  and  pus- 
tules succeeding  each  otlier  and  uniting  to  form  patches.  In  some  cases 
the  lesion  is  conveyed  from  tiie  hands  or  other  parts  by  the  act  of  scratch- 
ing the  genitals.  The  occurrence  of  a  localized  eczema  of  the  penis  or  of 
the  extra-genital  region  of  the  female  should  always  excite  suspicion.  The 
points  of  diagnostic  significance,  therefore,  are  the  irregular  mingling  upon 
the  penis  or  mons  Veneris,  of  a  number  of  small  papules  and  pustules,  the 
excessive  itching,  and  perhaps  the  presence  elsewhere  of  a  similar  eruption. 
Tlie  discovery  of  the  acarian  furrow  establishes  the  diagnosis  beyond  doubt. 

Tiie  treatment  is  very  simple.  The  best  application  is  a  salve  composed 
principally  of  balsam  of  Peru,  as  follows  : — 

I^.     Bals.  Peniv.  fi] 81 

Gelati  Petrol(3i  ^j 30| 

M. 

After  immersion  of  the  affected  parts  in  quite  hot  water  containing 
a  little  borax,  the  above  ointment  should  be  thoroughly  rubbed  in  and 
afterwards  spread  upon  lint  and  applied  to  the  region. 

The  cause  of  this  affection,  as  of  the  itch  in  other  localities,  is  the  insect, 
the  acarus  scahei. 

Phtheiriasis  Pubis. 

Phtheiriasis,  commonly  called  lousiness,  is  an  affection  caused  by  animal 
parasites  or  pediculi,  of  which  there  are  three  varieties:  the  pediculus 
capitis,  the  pediculus  corporis,  or  vestimentorum,  and  tlie  pediculus  pubis. 
The  first  two  attack  the  head  and  body,  the  third  is  usually  limited  to  the 
extra-genitals,  and  we  shall  confine  our  description  to  the  changes  pro- 
duced by  it  in  these  parts. 

The  pediculus  pubis,  also  called  the  crab-louse,  piithirius  inguinalis, 
phthirius  pubis  and  morpio,  is  the  smallest  variety.  Its  body  resembles  in 
shape  a  shield,  being  broad,  flat,  and  rounded.  Its  head  is  proportionately 
Large,  and  is  somewhat  the  shape  of  a  fiddle.  From  each  side  of  the  head 
project  stout,  five-jointed  antenna?,  anterior  to  which  are  two  small  eyes. 
There  is  no  indentation  between  the  thorax  and  the  abdomen.  To  the 
former  are  attached  six-jointed,  hairy  legs  with  strong  claws,  and  along 
the  margin  of  the  abdomen  are  eight  conical  feet,  from  each  of  which  pro- 
ject from  four  to  ten  bristles.  The  insect  has  a  very  light-brown  color, 
and  is  somewhat  translucent.  The  female  is  larger  than  the  male,  and 
has  a  triangular  indentation  at  its  posterior  part. 

Although  the  insect  is  usually  found  only  in  the  pubic  and  femoral  re- 
gions, it  is  sometimes  transferred  by  tlie  fingers  to  the  axilla  and  to  the 
eyebrows  and  lashes. 

The  presence  of  the  parasite  upon  the  genitals  is  made  known  by  an 
intense  pruritus,  which  is  paroxysmal.  In  many  cases  the  itching  is  trifling 
during  the  day  and  severe  at  night.     Very  often  the  insects  are  so  few  that 


The  formivla  on  p.  573  should  read — 

I^.     Hydrarg.  Bichlor.  gr.  viij       ....  50 

Aquae  Cologn., 

Aquae,  aa  ^ij         .,....,.     60 
M. 


TINEA    OR    PITYRIASIS    VERSICOLOR.  573 

they  may  be  overlooked,  except  upon  the  most  careful  search.  In  some 
cases  no  visible  lesions  of  the  skin  are  produced.  In  other  cases  we  may 
find  crusts  of  dried  blood,  as  small  as  the  head  of  a  pin.  These  result,  not 
from  the  bite  of  the  insect,  but  from  the  puncture  of  a  sucking  apparatus, 
or  haustellum.  In  addition  to  these  lesions,  we  sometimes  find  secondary 
changes,  such  as  hypera^mia,  congestion  of  the  hair  follicles  and  even  pus- 
tulation.  Examination  of  the  hairs  shows  dirty  white  particles  attached 
to  their  shafts,  which  are  the  nits  or  ova  of  the  parasite.  Upon  separating 
the  hairs  small,  light-brown  spots,  sometimes  mistaken  for  particles  of  dirt, 
may  be  discovered.  On  each  side  of  this  body,  wdiich  is  the  pediculus,  may 
be  seen  its  minute  hair-like  legs.  This  feature  is  diagnostic,  and  should 
be  looked  for  in  every  case  of  pruritus  of  the  genitals. 

Treatment. — The  treatment  of  phtheiriasis  pubis  is  strictly  local  and 
is  very  efficacious,  if  carefully  applied.  Although  mercurial  ointment  is 
considered  a  specific  by  the  laity,  its  use  is  objectionable  on  account  of  the 
acute  and  severe  dermatitis  which  it  often  produces.  The  most  eligible 
preparation  is  the  following  solution,  which  may  be  sopped  on  the  parts 
freely  once  or  twice  a  day  and  allowed  to  dry  : — 

R.     Hydrarg.  Biclilor.  gr.  viij   ....  50 

Aquse  Cologn., 

Aquae,  aa  gij 60 

M. 

After  its  use  a  warm  sitz  bath  is  very  beneficial.  Care  should  be  taken 
that  the  underclothing  and  bed-linen  are  thoroughly  cleansed  and  pressed 
with  a  hot  ii'on.  In  cases  of  extreme  persistence  of  the  parasites  it  may 
be  necessary  to  cut  the  hair  from  the  pubes.  Besides  the  solution  already 
recommended  the  tincture  of  delphinium,  or  larkspur,  is  equally  efficacious 
and  pleasant  to  apply. 

Tinea  or  Pityriasis  Versicolor. 

This  parasitic  skin-affection  is  so  often  mistaken  for  syphilis,  and  those 
affected  with  it  are  so  frequently  subjected  to  unnecessary  mercurial  treat- 
ment that  a  description  of  the  lesion  seems  desirable. 

It  begins  on  the  chest  as  small,  round,  light  yellow  spots,  which  may  be 
slightly  or  not  at  all  elevated  above  the  surface.  These  spots  may  be  scaly, 
or  smooth  and  sliining;  they  seem  to  be  seated  around  the  sebaceous  and 
sweat  follicles,  and  they  gradually  extend  until  quite  large  patches  are 
formed.  When  the  eruption  is  chronic  and  very  extensive,  numerous 
small  patches  surround  those  of  larger  size,  an  appearance  which  has  been 
compared  to  a  map  representing  continents  and  islands.  The  color  varies 
from  a  light  yellow^  to  a  dark  brown  or  even  coppery  hue.  When  the  cir- 
culation is  active,  or  the  lesion  is  irritated  by  scratching,  the  patches  may 
become  red. 

In  some  cases  this  affection  is  limited  to  the  breast,  while  in  others  it 
extends  over  the  entire  anterior  surface  of  the  trunk,  sto[)pingat  tlie  neck. 


5*74  CUTANEOUS    AFFECTIONS    OF    THE    GENITALS. 

perhaps  invading  the  axilhv  to  some  extent  and  encroaching  slightly  upon 
the  thighs.  It  sometimes  begins  upon  the  mons  Veneris  and  about  the 
inguinal  region,  but  very  rarely  extends  around  to  the  back.  It  occurs  in 
both  sexes,  perhaps  with  greater  frequency  in  females  than  in  males.  It 
is  of  common  occurrence  among  those  who  perspire  freely,  in  weak  and 
debilitated  subjects,  and  especially  those  suffering  from  pulmonary  troubles. 
On  the  other  hand,  those  in  robust  health  are  by  no  means  exempt. 

The  affection  is  sometimes  attended  by  mild  pruritus,  or  tingling  and 
slight  itching  may  be  complained  of  only  when  the  patient  is  warm  or  ex- 
cited.    In  very  rare  cases  the  pruritus  is  severe  and  troublesome. 

The  disease  runs  a  slow,  chronic  course,  sometimes  persisting  for  years ; 
again  it  sometimes  disappears  in  winter  to  return  in  summer.  It  is  only 
mildly  contagious,  cases  of  undoubted  infection  from  the  parasitic  fungi 
being  not  often  seen.  Instances  have  been  known  in  which  husbands  have 
had  the  disease  for  years  without  infecting  their  wives.  The  affection  is 
perpetuated  by  the  wearing  of  flannel,  wliich  seems  to  be  a  nidus  for  the 
parasite,  and  it  is  particularly  persistent  in  uncleanly  persons.  Yet  in 
some  cases  the  utmost  cleanliness  does  not  prevent  a  recurrence. 

The  affection  is  not  seen  in  very  young  persons,  but  in  those  of  adult 
and  middle  age.  Some  authors  have  claimed  that  a  peculiar  state  of  the 
system,  generally  one  of  debility,  is  essential  to  its  development.  In  our 
opinion  free  pers[)iration  seems  to  favor  its  appearance,  which  is  quite  inde- 
pendent of  a  morbid  condition  of  th,e  system. 

Tinea  versicolor  is  a  distinctly  parasitic  affection,  being  caused  by  a 
vegetable  parasite,  the  microspor  on  furfur. 

Diagnosis This  affection  is  sometimes  regarded  as  an  evidence  of 

syphilis  or  of  a  disordered  condition  of  the  liver.  It  certainly  has  no  rela- 
tion whatever  to  hepatic  derangement,  and  resembles  syphilis  only  in  the 
l)rown  or  sometimes  coppery  color  of  the  patches.  The  distinction  is  very 
readily  made.  Syphilitic  coppery  stains  are  always  discrete  and  not  con- 
fluent; tliey  are  scattered  all  over  the  trunk  as  well  as  elsewhere  on  the 
body  ;  they  are  sharply  circumscribed,  and  rarely  if  ever  scaly,  are  not 
itchy,  and  are  not  effaced  by  scratching,  as  is  the  case  with  patches  of 
tinea.  Finally,  the  scales  of  sy[)hilis  are  simply  epithelial,  while  those  of 
tinea  contain  the  spores  of  the  [)arasite. 

Treatment The  patches  should  be  well  scoured  with  a  pad  of  flan- 
nel smeared  witli  soap.  Strong  solutions  of  sal  soda  or  borax  employed 
with  active  friction  are  of  benefit.  After  a  thorough  washing,  either  of 
the  following  parasiticide  lotions  may  be  applied : — 

I^.     Sodse  Hyposulphitia  giij     ,     .     ,     .     121 
Aquje  §iv 120| 

S,  To  be  freely  sopped  on  the  parts, 

I^.     Hydrarg.  Bichlor.  gr,  v       ....         130 

Aqufe  Cologn.  §ss 15 

Aquae  §iijss 105] 

M, 


LUPUS    ERYTHEMATOSUS    OF    THE    PENIS.  575 

After  each  application  clean  underclothing  should  be  put  on,  and  that 
previously  worn  must  be  boiled  for  a  long  time,  in  order  to  prevent  rein- 
fection. 

Lupus  Erythe^iatosus  of  the  Penis. 

Lupus  erythematosus,  although  occurring  most  commonly  upon  the 
face,  occasionally  attacks  the  penis,  sometimes  being  limited  to  the  latter 
region  and  again  appearing  at  the  same  time  on  other  parts  of  the  body. 

The  lesion  begins  as  a  small,  circular,  red  spot,  slightly  elevated  and 
covered  with  a  few  small  adherent  scabs.  The  margin  is  sometimes  raised, 
while  the  surface  may  present  numerous  little  elevations  caused  by  plug- 
ging and  swelling  of  the  sebaceous  follicles.  The  patch  increases  in  size, 
healing  taking  place  at  its  centre  while  its  border  extends.  The  eruption 
has  a  dull  red,  but  not  coppery,  color,  and  is  seldom  attended  by  any  ab- 
normal sensations.  Its  course  is  very  chronic.  In  two  cases  seen  by  us 
the  lesion  began  on  the  outside  of  the  prepuce. 

Diagnosis This  affection  may  be  mistaken  for  the  papular  syphilide, 

in  its  ringed  form,,  or  for  psoriasis.  The  rings  of  syphilitic  papules  gene- 
rally have  a  coppery  red  color,  are  very  slightly  scaly,  and  the  inclosed 
area  of  skin  is  normal.  The  patches  of  psoriasis  are  usually  multiple,  are 
very  scaly,  and  coexist  with  similar  ones  elsewhere. 

Treatment The  treatment  of  this  affection  is  not  always  satisfactory 

in  its  results.  As  an  application  mercurial  plaster  or  a  dilute  mercurial 
ointment  may  be  tried.  Electrolysis  may  be  employed  at  the  advancing 
border  of  the  patch.  In  case  these  methods  fail  it  may  be  well  to  resort 
to  excision  of  the  entire  patch  unless  too  large. 


576        AFFECTIONS  OF  APPENDAGES  OF  THE  SKIN. 


CHAPTER    XIV. 
AFFECTIONS  OF   THE  APPENDAGES  OF  THE   SKIN. 

AFFECTIONS  OF  THE  HAIR. 

Alopecia  is  one  of  the  most  common  symptoms  of  syphilis.  It  varies 
from  slight  to  almost  complete  loss  of  hair,  which  is  rarely  permanent, 
and  its  course  may  be  rapid  or  chronic.  It  is  attended  by  no  subjective 
symptoms,  such  as  heat  or  itching,  and  in  most  cases  there  are  no  marked 
lesions  of  the  scalp,  while  in  other  cases  the  hair  follicles  may  be  involved 
by  macules,  papules,  pustules,  or  ulcers.  The  eyebrows,  the  beard  and 
moustache,  the  hair  of  the  pubes  and  axillte  may  also  be  involved.  The 
eyelashes  are  seldom  attacked,  except  by  ulcerative  lesions,  and  alopecia 
never  exist  elsewhere  without  affecting  the  scalp. 

There  are  two  varieties  of  syphilitic  alopecia,  one  consisting  of  a  simple 
thinning  of  the  hair,  and  the  other  of  loss  of  the  hair  in  patches. 

On  the  scalp  the  result  of  alopecia  is  generally  striking,  but  it  may  be 
so  slight  as  to  pass  unnoticed,  the  hair  merely  being  thinned.  The  hair 
may  be  lost  in  one  or  more  patches,  which  vary  in  size  and  occur  without 
symmetry  or  order ;  they  may  be  as  large  as  the  palm  of  one's  hand,  and 
several  may  fuse  together.  Their  outline  is  irregular,  and  they  show  no 
tendency  to  assume  a  circular  form.  The  surface  of  the  patches  is  rather 
dry  and  somewhat  scaly ;  the  follicles  are  quite  prominent,  and  scattered 
irregularly  may  be  a  few  long  hairs,  sometimes  one  or  more  tufts,  and  minute 
hairs.  The  surface  of  the  scalp  is  dry,  and  presents  a  few  furfuraceous 
scales.  In  patients  who  have  been  subject  to  seborrhoea  capitis,  or,  as  it 
is  generally  known,  pityriasis  capitis,  this  condition  is  often  much  more 
marked. 

The  hair  follicles  may  be  involved  by  erythematous  spots,  papules,  or 
pustules,  coincidently  with  a  general  eruption.  In  such  cases  the  loss  of 
liair  is  generally  slight  and  scattered.  The  arch  of  the  eyebrows  may  be 
interrupted  by  the  fall  of  a  few  hairs,  or  may  be  totally  destroyed,  giving 
the  jjatient  a  very  peculiar  appearance.  In  the  beard,  in  the  axilla?,  and 
upon  the  pubes,  the  loss  of  hair  may  also  be  partial,  complete,  or  in  patclies. 

Syphilitic  alopecia  is  peculiar  to  the  secondary  period,  and  generally 
begins  about  the  third  month,  at  the  decline  of  the  earlier  secondary  symp- 
toms. It  may  occur  at  any  time  before  the  end  of  the  second  year,  and 
is  very  frequently  associated  with  cachexia. 

Alopecia  is  undoubtedly  a  result  of  impaired  nutrition  of  the  hair  folli- 
cles, due  to  the  adynamic  influence  of  syphilis.  Under  the  microscope 
the  hair  bulb,  instead  of  appearing  expanded  and  rounded,  is  seen  to  be 


AFFECTIONS    OF    THE    HAIR.  577 

wedge-sbaped  or  otherwise  imperfectly  formed.  It  is  probable  that  the 
papilla  no  longer  nourishes  the  bulb,  which  therefore  withers  and  contracts, 
the  hair  becoming  detached.  For  a  short  time  the  hair  may  remain  in  the 
follicle  held  by  the  root-sheath.  In  this  case  a  new  hair  will  probably 
grow  ;  but  should  inflammatory  or  ulcerative  changes  occur  in  the  follicles, 
or  when  pustules  attack  the  scalp,  and  sometimes  even  when  erythematous 
spots  and  papules  occur,  the  papilla  may  be  destroyed  and  the  follicle  be- 
come obliterated,  permanent  baldness  resulting.  This  hapjiens  in  a  marked 
degree  in  connection  with  late  tubercles  and  gummatous  ulcers. 

Diagnosis. — The  diagnosis  of  syphilitic  alopecia  is  to  be  made  from 
pityriasis  capitis  (seborrhoea),  senile  baldness,  and  alopecia  areata.  The 
suddenness  of  invasion  and  the  generally  marked  character  of  the  bald- 
ness in  syphilitic  alopecia  and  its  non-inflammatory  course  are  in  marked 
contrast  with  the  chronic  course,  and  the  scaly  and  somewluit  pruritic 
condition  of  pityriasis  capitis.  Moreover,  the  suspicion  of  syphilis  is 
confirmed  by  the  history  of  the  case  and  tlie  discovery  of  other  specific 
lesions. 

Senile  alopecia,  incorrectly  so  called  since  it  usiuilly  begins  in  middle 
life,  extends  backwards  from  the  forehead  or  begins  at  the  vertex,  and  is 
wholly  unlike  the  syphilitic  affection.  Moreover,  the  scalp  is  smooth  and 
shiny,  and  the  follicular  openings  are  no  longer  visible. 

Alopecia  areata  is  much  more  common  in  children  than  in  adults,  and 
occurs  in  round,  oval,  or  serpiginous  jiatches,  the  liair  on  other  parts  of 
the  scalp  being  preserved.  The  surfaces  of  the  patches  are  very  smooth 
and  polished,  and  of  a  yellowish-white  color;  they  are  not  scaly,  and  they 
are  completely  destitute  of  hair. 

The  prognosis  of  syphilitic  alopecia  is  in  general  good.  In  some  cases 
the  loss  of  hair  is  so  extensive  and  its  renewal  so  slow  that  permanent 
baldness  seems  to  be  inevitable.  The  main  points  upon  which  to  base  the 
prognosis  are  the  extent  of  the  baldness,  its  duration,  and  the  patient's 
general  health.  If  the  affection  has  been  severe,  and  has  existed  for  some 
time,  if  treatment  has  been  neglected  and  incomplete,  and  if  cachexia  has 
taken  place,  the  prognosis  must  be  veiy  guarded. 

The  treatment  of  syphilitic  alopecia  is  that  of  the  secondary  period. 
Although  we  cannot  agree  with  Fournier  that  mercurial  treatment  is  the 
only  requisite,  we  are  confident  that  it  sliould  never  be  neglected;  and  we 
believe  that  local  treatment  also  should  l)e  employed.  Tiie  indications 
are  to  apply  stinmlation  with  the  hope  of  restoring  the  healthy  condition 
of  the  scalp.  Frequent  shampooing  of  the  head  with  brisk  friction  is  of 
much  benefit.  For  this  purpose  we  prefer  a  simple  tincture  of  German 
green  soap,  made  as  follows  : — 

R.     Saponis  Viridis,  ^ij 641 

A<iu;e  Cologn.,  giv 124| 

M.     Filt.-r. 

The  scalp  having  been  moistened  with  warm  water,  it  should  be  rubbed 
with  ar  sponge  containing  3'j  (<^)  of  tl'i^  preparation.     Care  must  be  taken 
37 


578  AFFECTIONS    OF    APPENDAGES    OF    THE    SKIN. 

to  completely  expose  the  scalp.     After  washing  and  thoroughly  drying 
the  hair,  the  surface  should  be  rubbed  with  the  following  : — 

I^.    Tinct.  Cantharid.,  ,^.iss 45 

Tiiict.  Capsici,  giv 16 

01.  Ricini,  ^jss 4.5 

Alcohol  (95)"  ad  I viij 250 

Perfume,  q.  s. 

M. 

This  makes  an  excellent  tonic.  Some  authors  recommend  a  similar 
compound  with  spirits  of  hartshorn  added  ;  we  never  use  this  ingredient, 
since  it  dries  the  hair  and  is  inferior  to  green  soap  tincture  as  a  detergent. 
"We  have  also  used  a  solution  of  quinine  as  follows,  but  have  never  been 
struck  by  its  efficacy  : — 

I^.     Quill.  Sulph.,  5.i 4 

Spii'.  Myrci.-e,  §iijss 112 

01.  Amygdal.  Dulc,  '^iv 1(3 

M.     To  be  sliakeu  before  it  is  rubbed  in. 

Various  essential  oils,  such  as  sabine,  thyme,  cedar,  etc.,  have  also  been 
recommended,  but  the  odor  is  objectionable,  and  their  stimulating  properties 
are  not  remarkable.  The  best  local  treatment  is  the  daily  use  of  the  can- 
tharidal  tonic,  preceding  its  application  every  second  or  third  day  by  fric- 
tion with  the  green  soap  tincture.  In  very  rebellious  cases,  in  which  the 
patches  are  large,  even  greater  stimulation  may  be  required,  and  is  best 
accomplished  by  blistering  with  cantharidal  collodion,  repeated,  if  neces- 
sary, in  a  week  or  two,  and  followed  by  the  milder  treatment  directed 
above. 

Affections  of  the  Nails. 

Syphilitic  affections  of  the  nails  are  of  two  varieties :  in  one,  called 
oiychia,  the  disease  begins  in  the  nails  themselves ;  and  in  the  other, 
called  perionychia,  it  begins  in  their  vicinity  and  involves  them  second- 
arily. Their  course  is  chronic,  and  may  be  mild  or  severe  and  destructi.'e. 
They  generally  appear  within  the  first  two  years  of  syphilitic  infection, 
but  may  be  much  later. 

In  syphilitic  onychia  the  changes  may  be  dry  and  confined  to  the  nail- 
substance,  or  the  nail  may  be  separated  from  its  bed. 

In  the  dry  form,  onychia  sicca,  called  by  Fournier  "friable  onychia" 
(onyxis  craguete),  the  nail  gradually  loses  its  lustre  and  transparency  at 
its  free  edge  and  assumes  u  dull  yellow  color;  sometimes  the  disease  is 
limited  by  a  distinct  line  of  demarcation,  or  the  whole  nail  may  be  in- 
volved. The  edge  of  the  nail  becomes  thickened  and  brittle,  readily 
cracks,  and  may  be  deeply  serrated.  Its  surface  is  rough  and  presents 
shallow,  longitudinal  fissures  and  minute  depressions,  which  collect  the 
dirt.  The  epidermis  under  and  beyond  tiie  free  margin  is  usually  thick- 
ened and  scaly.  Very  often  there  is  but  slight  inconvenience  from  the 
disease  and  the  deformity  may  be  remedied  by  careful  paring  of  the  nail. 
Treatment  results  in  the  gradual  pushing  forward  of  the  diseased  portion, 
leaving  a  healthy  nail.     In  neglected  cases,  especially  if  the  parts  arc  irri- 


AFFECTIONS    OF    THE    NAILS.  579 

tated,  the  whole  of  the  affected  nail  may  be  lifted  off  or  pushed  forwards 
by  a  new  nail,  which  may  at  first  be  imperfect. 

Separation  of  the  nail  takes  place  not  infrequently  in  the  early  part  of 
the  secondary  stage  of  syphilis,  and  may  be  partial  or  complete.  The 
process  may  be  so  insidious  and  it  may  cause  so  little  inconvenience, 
especially  with  careless  persons,  and  when  the  toe-nails  are  affected,  that 
several  nails  may  fall  without  attracting  the  notice  of  the  patient.  It 
begins  at  the  free  border  of  the  nail,  being  limited  at  first  to  a  portion  of 
its  breadth.  It  gradually  extends  towards  the  base  of  the  nail,  involving 
one-third  to  one-half  its  length,  and  possibly  its  entire  breadth.  In  neo-- 
lected  cases  the  whole  nail  may  be  affected  and  thrown  off.  The  diseased 
portion  of  the  nail  assumes  a  greenish-brown  color,  and  the  matrix  beneath 
presents  more  or  less  healthy  granulations.  When  the  destruction  of  the 
nail  has  been  partial,  the  healthy  portion  pushes  forward  and  covers  the 
denuded  parts  ;  when  it  has  been  complete,  an  entirely  new  nail  is  formed. 
Only  one  nail  may  be  affected,  or  several  may  be  involved  simultaneously 
or  in  succession,  those  of  the  hands  more  frequently  than  those  of  the  feet. 
Fournier  describes  a  hypertrophic  onychia,  in  which  the  thickening-  of 
the  nail  is  excessive.  It  involves  the  nails  of  the  fingers  more  frequenth- 
than  those  of  the  toes,  and  usually  attacks  more  than  one  nail.  He  thinks 
women  are  more  subject  to  it  than  men. 

There  is  also  an  affection  of  the  nails,  of  which  we  have  seen  but  two 
well-marked  instances  in  men  suffering  with  syphilitic  cachexia,  which 
seems  to  be  a  local  necrosis.  The  nail  becomes  opaque  and  whitish,  in 
spots  the  size  of  a  pin-head.  These  spots,  of  which  there  may  be  from 
two  or  three  to  ten,  are  formed  by  depressions  of  the  surface  of  the  nail 
which  finally  reach  the  matrix,  leaving  minute  and  sharply-cut  holes. 

There  are  two  forms  of  perionychia:  an  ulcerative  and  an  indolent 
form,  which  is  usually  non-ulcerative. 

The  non-ulcerative  form  may  attack  the  entire  attached  margin  of  the 
nail,  or  its  lunula,  or  one  of  its  lateral  margins.  The  border  of  the  nail 
to  the  width  of  about  one  line  is  thickened  in  consequence  of  specific  infil- 
tration, and  there  is  a  more  or  less  complete  papular  rim  around  it.  The 
color  is  dull  red,  which  pales  on  pressure,  and  the  surface  is  slightly  scaly. 
This  condition  may  persist  for  a  long  time,  until  the  nail  becomes  of  a  dull 
color  and  is  traversed  by.  shallow  transverse  furrows,  showing  impaired 
nutrition.  As  a  result  of  pressure  or  irritation  ulceration  may  occur  at 
tlie  angle  of  reflection  of  the  skin,  and  may  extend  beneath  the  nail,  which 
is  finally  loosened  and  thrown  off.  Sometimes  when  only  a  lateral  margin 
is  aft'ected,  the  ulceration  reaches  but  a  siiort  distance,  and  the  nail  re- 
mains and  excites  a  chronic  suppurative  inflammation,  which  is  cured  only 
after  its  partial  or  complete  ablation. 

The  ulcerative  form  of  perionychia  may  occur  at  any  time  during  the 
secondary  period,  and  varies  greatly  in  severity.  It  may  begin  as  a  pap- 
ule or  a  pustule  at  some  part  of  the  nail  margin,  or  a  small  ulceration  or 
fissure'at  the  lunula  is  the  change  first  noticed.  In  eitlier  case  the  in- 
flammation gradually  increases,  and  ulceration  extends  along  the  sulcus  at 


580  AFFECTIONS    OF    ATPEXDAGES    OF    THE    SKIN. 

the  attached  margin  of  the  nail.  The  process  may  be  limited  to  the  lun- 
ula or  to  a  portion  of  the  nail  border,  or  it  may  involve  the  entire  length 
of  the  sulcus.  When  the  lunula  is  invaded  the  affection  is  very  obsti- 
nate ;  tiie  base  of  the  nail  soon  loses  its  transparency  and  becomes  detached 
to  the  extent  of  about  a  line.  The  ulceration  which  extends  under  the 
nail  itself,  and  may  be  for  a  time  inaccessible,  constantly  secretes  an  offen- 
sive pus.  The  whole  nail  may  be  gradually  undermined,  or  the  parts  may 
be  denuded  to  a  limited  extent  by  destruction  of  the  attached  margin. 
Much  depends  on  the  early  treatment  of  the  ulceration;  if  it  be  speedily 
checked,  a  new  nail  forms  and  covers  the  diseased  parts,  pushing  the  old 
nail  before  it. 

When  the  ulceration,  which  is  likely  to  be  particularly  intense  at  the 
lunula,  is  severe,  the  whole  matrix  becomes  involved,  and,  after  the  nail 
has  been  thrown  off,  it  presents  a  yellowish,  somewhat  pultaceous  surface, 
surrounded  by  the  swollen  and  ulcerated  nail  margin.  Soon  the  ulcera- 
tion shows  a  tendency  to  localize  itself  at  the  basal  margin,  while  the  sur- 
face of  the  matrix  becomes  covered  with  a  dirty  yellow,  firm,  and  uneven 
epithelial  tissue.  Unless  ulceration  involves  the  lateral  margins,  which  it 
seldom  does,  a  thin  spicula  of  nail  forms  along  the  whole  length  of  the 
sulcus.  In  such  a  typical  case  the  whole  phalanx  is  swollen  and  bulbous, 
and  the  matrix  is  hypertrophied,  pulpy,  and  of  a  reddish-yellow  color. 
Attempts  at  formation  of  a  new  nail  are  seen  upon  the  matrix  and  at  its 
margins.  Owing  to  its  dense  structure  the  matrix  itself  is  very  resistant, 
and  if  left  without  treatment  merely  becomes  thickened  as  the  ulceration 
increases. 

If  the  base  of  the  nail  has  not  been  too  extensively  destroyed  it  retains 
a  surprising  degree  of  reparative  power.  A  new  nail  ap[)ears  and  covers 
the  matrix,  unless  it  be  excessively  hypertrophied,  and  may  be  quite  as 
good  as  the  original  nail.  In  some  cases  a  perfect  nail  results  only  after 
several  renewals.  It  sometimes  happens  that  the  nail-producing  power  of 
the  distal  portion  of  the  matrix  is  impaired,  so  that  the  new  nail  fails.to 
cover  as  much  of  tlie  finger  as  did  its  predecessor.  When  this  condition 
coexists  with  total  destruction  of  the  base,  the  whole  matrix  is  converted 
into  a  cicatrix. 

When  the  inflammation  attacks  the  base  and  one  side  of  the  nail  it  in- 
volves the  subjacent  matrix,  and  if  its  intensity  Jn  the  latter  region  equals 
that  at  the  base,  separation  of  the  nail  at  the  side  soon  takes  place,  and 
permits  the  free  application  of  remedies.  Such  cases  are  of  much  less 
gravity. 

In  persons  whose  hands  are  exposed  to  irritants,  perionychia  may 
begin  under  the  free  edge  of  the  nail,  generally  of  the  index  or  middle 
finger.  Slight  pain  attracts  the  attention  of  the  patient,  and  he  finds  a 
brownish-red  crust  beneath  the  nail,  removal  of  which  exposes  an  ulcer 
extending  along  more  or  less  of  the  nail's  breadth.  On  removal  of  the 
irritation  and  the  use  of  proper  remedies  the  ulcer  soon  heals  ;  in  case  of 
neglect  it  extends  and  rapidly  involves  the  whole  of  the  matrix,  or  it 
creeps  slowly. along,  tlie  nail  assuming  a  dull,  yellowish-brown  color,  the 


AFFECTIONS    OF    THE    NAILS.  581 

matrix  exhibiting  a  yellow,  ulcerated  appearance,  and  the  wliole  phalanx 
becoming  enlarged,  until  the  base  of  the  nail  is  reached,  when  a  con- 
dition similar  to  that  of  inflammation  of  the  lunular  region  is  induced. 

All  forms  of  syphilitic  perionychia  are  very  chronic,  rarely  lasting  less 
than  one  or  two  months,  and  sometimes  continuing  a  year.  At  first  they 
may  cause  scarcely  any  inconvenience,  and  for  this  reason  they  are  often 
neglected.  Pain  begins  when  the  inflammation  is  fully  developed,  espe- 
cially if  the  base  of  the  nail  is  involved.  In  severe  cases  the  whole  finger 
and  even  the  hand  may  be  affected  by  tlie  inflammation  ;  the  lymphatics 
of  the  arm  are  very  painful,  and  there  is  pronounced  systemic  reaction. 

The  nails  of  the  fingers  and  of  the  toes  are  attacked  with  equal  frequency, 
those  most  used  and  most  exposed  being  the  most  liable.  In  general  only 
one  finger  is  affected,  sometimes  a  finger  of  each  hand,  or  two  fin- 
gers of  the  same  hand,  either  simultaneously  or,  more  commonly,  in 
succession. 

Diagnosis — Chronic  eczema  and  psoriasis  of  the  hand  are  sometimes 
followed  by  changes  in  the  nail  similar  to  those  of  syphilitic  friable 
onychia.  The  question  may  be  settled  by  the  previous  history  of  the 
case. 

Ulcerative  perionychia  has  been  mistaken  for  the  initial  lesion  of  syphilis. 

A  chancre  of  the  finger  is  seldom  met  with  except  in  the  case  of  mid- 
wives  and  surgeons,  and  is  always  accompanied  by  characteristic  enlarge- 
ment of  the  epitrochlear  or  axillary  ganglia. 

Severe  perionychia  resembling  the  sy[)hilitic  form  is  sometimes  seen  in 
broken-down  and  cachectic  subjects.  Its  occurrence  should  always  excite 
the  suspicion  of  syphilis. 

The  prognosis  of  friable  and  of  hypertrophic  onychia  is  good,  since  they 
are  generally  mild  and  transient.  The  same  is  true  when  separation  of 
the  nail  occurs,  the  morbid  condition  being  soon  relieved  by  proper 
treatment. 

Tlie  non-ulcerative  form  of  perionychia  usually  distresses  the  patient  on 
account  of  its  attacking  several  nails,  but  it  occasions  slight  inconvenience 
and  is  readily  cured. 

The  ulcerative  forms  are  always  troublesome  and  often  very  painful 
affections,  and  the  prognosis  should  always  be  guarded.  The  curlier 
separation  of  the  nail  occurs  and  the  focus  of  disease  at  the  base  of  the 
nail  is  reached  by  local  applications,  the  sooner  may  relief  be  expected. 
New  and  comely  nails  sometimes  develop  even  after  prolonged  and  intense 
basal  ulceration.  In  nearly  all  cases  where  the  perionychia  is  latei'al  or 
at  the  free  border  of  the  nail,  a  perfect  nail  may  be  predicted. 

The  growth  of  the  new  nail  is  very  slow,  and  the  spiculai  at  tiie  edges 
and  the  uneven  plates  which  often  form  on  the  surface  of  the  matrix,  are 
important  indications  of  retention  of  the  nail-producing  power.  The  new 
nail  is  often  imperfect  at  first,  being  ridged  and  irregular,  and  it  is  some- 
times permanently  shorter  than  the  old  one. 

Treatment Internal  treatment  is  required  in  all  forms  of  syphilitic 

affections  of  the  nails. 


582  AFFECTIONS    OF    APPENDAGES    OF    THE    SKIN. 

Friable  onychia  calls  for  no  otlier  local  treatment  than  careful  trimming 
of  the  nails  and  prevention  of  irritation. 

In  case  of  separation  of  the  nail,  exposure  of  the  matrix  and  the  appli- 
cation every  day  or  two  of  liquor  potasste,  followed  by  the  use  of  an 
ointment  composed  of  one  part  of  mercurial  and  two  parts  of  diachylon 
ointment,  will  arrest  the  disease.  The  simple  form  of  perionychia  may 
be  cured  by  the  use  of  this  ointment. 

In  ulcerative  perionychia  the  diseased  surface  should  be  exposed  as  soon 
as  possible  and  cauterized  with  nitric  acid  or  a  strong  solution  of  nitrate 
of  silver,  allaying  inflammatory  reaction  with  water  dressings.  Subse- 
quently iodoform  or  powdered  nitrate  of  lead  may  be  applied,  and  the 
phalanx  be  enveloped  in  diachylon  ointment.  The  profuse  granulations 
of  the  matrix  may  require  the  use  of  a  strong  solution  of  caustic  potassa 
(5'-5u  01"  i^')-  Prolonged  immersion  of  the  hand  in  very  warm  water 
containing  powdered  borax  (5'j-Qi)  diminishes  the  swelling,  and  removes 
the  secretions.  The  application  of  a  bandage  over  the  ointment.  India- 
rubber  finger  stalls,  or  gutta-percha  tissue,  may  be  used  to  reduce  the 
swelling.     Care  must  be  taken  to  api)ly  the  pressure  gradually. 

In  addition  zinc  and  belladonna  ointments  or  Goulard's  extract  may  be 
used  to  meet  special  indications.  The  mixture  of  diachylon  witli  mercurial 
ointment  is  smoother  and  more  efficient  than  the  ordinary  mercurial  plaster 
or  the  emplastruin  de   Vigo. 


ERYTHEMA.  583 


CHAPTER   XV. 
GENERAL    REMARKS   UPON    AFFECTIOXS   OF 

M  u  c  o  u  s  :\i  E  :\i  b  r  a  x  e  s  . 

Attempts  have  been  made  by  several  authors,  and  especially  by  Babing- 
ton,  Ricord/  and  Baumes/  to  establish  a  classification  of  syphilitic  erup- 
tions upon  mucous  membranes  founded  upon  their  initial  lesion,  as  is  the 
case  with  the  syphilodermata.  There  is  no  doubt  that  the  manifestations  of 
syphilis  upon  these  two  regions  exhibit  a  general  correspondence,  which  in 
some  cases  is  almost  perfect.  At  the  same  time,  it  must  in  general  be 
confessed  that  although  points  of  resemblance  are  often  apparent  between 
syphilitic  eruptions  upon  cutaneous  and  mucous  surfaces  (which  are  indeed 
but  one  continuous  membrane),  yet  that  the  physical  conditions  in  which 

the  latter  are  placed — their  constant  moisture,  exposure  to  friction,  etc 

prevent  as  accurate  a  classification  as  we  are  able  to  establish  in  the  former. 

One  form  of  eruption  at  least,  the  pustular,  is  never  met  with  upon 
mucous  membranes. 

Erythema. 

Erythema  of  the  mucous  membranes  is  usually  identical,  in  the  time  of 
its  appearance  and  in  its  general  character,  with  the  same  eruption  upon 
the  skin.  Like  the  latter,  it  ordinarily  appears  six  or  eight  weeks  after 
contagion,  and  may  affect  any  of  the  outlets  of  mucous  canals,  although  it 
is  most  frequently  seen  upon  the  fauces,  pituitary  membrane,  and  genital 
organs,  and  in  many  instances,  doubtless,  fails  to  attract  attention.  It  is 
most  frequently  seen  upon  the  fauces  in  persons  exposed  to  sudden  changes 
of  temperature,  in  smokers,  and  in  those  who  are  subject  to  frequent 
attacks  of  cataiTli;  upon  the  vulva  in  women  who  have  frequent  sexual 
intercourse,  and  upon  the  glans  penis  in  men  with  a  long  prepuce.  It  may 
be  the  only  general  lesion  present,  or  more  freouently  it  is  accompanied 
by  other  early  manifestations.  It  may  occur  in  [)atches  like  the  erythema- 
tous syphilide  upon  the  skin,  as  in  a  case  described  and  figured  by  Kicord,^ 
of  erythema  of  the  glans  penis  coexisting  with  roseola  upon  the  trunk,  in 
which  the  former  eruption  was  arranged  in  circles  of  a  bright-red  color, 
inclosing  sound  portions  of  the  mucous  meml)rane,  and  closely  resembling 
the  roseola  upon  the  body.  As  a  general  rule,  however,  especially  upon 
the  fauces  and  vulva,  the  eruption  is  difiused  and  its  outline  well  defined. 

'  Notes  to  Hunter  on  Venereal,  p.  429  and  447. 

2  Traite  des  maladies  veneriennes,  ii.,  p.  443. 

3  Iconographie,  pi.  xv. 


584  AFFECTIONS    OF    MUCOUS    MEMBRANES. 

Syphilitic  erytlienia  of  the  mucous  membranes  may  exhibit  mere  redness 
of  the  surface  without  structural  cliauges  in  the  tissues.  In  some  cases, 
liowever,  the  epithelium  has  a  milky  hue,  and  becomes  detached  in  spots, 
giving  rise  to  erosions.  The  surface  is  sometimes  dry,  and  at  other  times 
smeared  with  an  abundant  secretion.  There  is  usually  but  little  swelling, 
except  when  the  vulva,  the  tonsils,  and  the  pituitary  membrane,  or  the 
labia  minora  are  affected.  In  the  case  of  the  nose,  the  swollen  folds  of 
mucous  membrane  may  interfere  Avitii  breathing  or  the  passage  of  the 
tears  through  the  lachrymal  ducts,  and  also  obstruct  the  P^ustachian  tubes. 
Aside  from  these  mechanical  annoyances,  it  is  attended  with  but  little  pain 
or  inconvenience. 

Tliis  eruption  often  disappears  quite  suddenly,  but  is  very  prone  to 
return.  Its  treatment  consists  in  the  internal  administi'ation  of  mercury; 
in  the  use  of  demulcent  gargles,  as  of  chlorate  of  potash  or  of  marshmallow, 
when  the  fauces  are  affected  ;  and  in  strict  attention  to  cleanliness,  and  in 
the  separation  of  opposed  surfaces,  when  the  genital  organs  are  involved. 

Mucous  Patches. 

"  The  name  '  mucous  patch'  is  applied  to  a  lesion  peculiar  to  syphilis, 
consisting  of  elevations  of  a  more  or  less  decided  rose-color,  frequently 
rounded  in  form,  the  surface  resembling  a  mucous  membrane,  and  situated 
in  the  neigldjorhood  of  the  outlet  of  mucous  canals,  especially  around  the 
genital  organs  and  anus,  upon  the  mucous  membrane  of  the  mouth,  and 
sometimes  upon  other  parts  of  the  body,  more  particularly  at  the  base  of 
the  nails  and  wherever  the  reflection  of  the  integument  upon  itself  forms 
natural  folds  in  the  skin."^ 

Tiiis  affection  is  one  of  the  earliest  and  most  frequent  secondary  mani- 
festations of  syphilis,  and  is  therefore  one  with  which  the  student  of  vene- 
real should  be  perfectly  familiar  ;  unfortunately  obstacles  have  been  placed 
in  the  way  of  acquiring  a  knowledge  of  it  by  the  confusion  Avhich  has  begn 
introduced  in  its  classification,  and  in  tlie  terms  which  have  been  applied 
to  it.  Different  authors,  according  to  the  views  they  have  entertained  of 
its  nature,  have  described  it  among  tubercles,  pustules,  and  papules,  and 
have  called  it  by  the  corresponding  names  of  "•  mucous  tubercle,"  "  pus- 
tule" or  "papule."  But  the  first  two  of  these  terms  are  entirely  inappro- 
priate, since  it  does  not  resemble  syphilitic  {)ustules  or  tubercles  in  its  time 
of  development,  its  symptoms,  course,  or  termination.  The  name  mucous 
papule  is  less  objectionable,  since  it  consists  in  most  instances  of  a  develop- 
ment of  the  paj)illa^  forming  broad  elevations  above  the  surrounding  sur- 
face; but  it  is  not  always  elevated,  and  may  even  be  excavated,  and  it  is 
moreover  so  distinct  in  its  characters  from  ordinary  pa[)ules,  and  of  such 
importance  as  an  indication  of  constitutional  infection,  as  to  entitle  it  to 
the  separate  name  adopted  by  MM.  Deville  and  Davasse,  which  I  shall 
here  retain. 

As  regards  its  histology,  this  lesion   is  found   to   consist  mainly  in   a 

'  Davasse  and  Deville,  Des  plaques  muqueuses,  Arch.  gen.  de  med.,  1845,  t.  ix. 


MUCOUS    PATCHES. 


585 


markecT  liyperplasia  of  the  papillae,  and  an  abundant  proliferation  of  cells 
in  the  mucous  layer  which  present  a  muddy  appearance  due  to  granular 
changes  in  their  protoplasm  and  segmentation  of  their  nuclei.  Tlie  sheaths 
of  the  hair  bulbs  and  the  walls  of  the  vessels  are  likewise  infiltrated  and 
thickened.  The  surface  of  the  patch  may  retain  its  epithelium,  or  the 
latter  may  become  detached  and  removed ;  it  may  either  become  depressed 
below  the  surrounding  surface  by  the  process  of  ulceration,  or  rise  above 
the  same  in  consequence  of  further  development  of  the  papilke,  whence 
arise  tlie  various  appearances  which  this  lesion  may  pi*esent. 

As  already  stated,  this  lesion  is  found  at  the  outlet  of  mucous  canals,  and 
upon  those  portions  of  the  external  integument  which  are  maintained  by  con- 
tact in  a  constant  state  of  warmth  and  moisture,  and  are  thus  very  nearly  in 
the  condition  of  mucous  surfaces.  Some  idea  of  its  comparative  frequency 
in  these  various  regions  may  be  obtained  from  the  following  tables : — 


In  130  men  observed  by  Bassereau,  mucous  patches 

Around  the  anus    ..... 
Upon  the  tonsils    ..... 

"       "     scrotum  .... 

"       "     lips 

"       "     glans  and  prepuce 

"      "     vehim  palati  .... 

"       "     tongue    ..... 

"      "     pillars  of  the  soft  palate 

"       "     internal  surface  of  the  cheeks 

Between  the  toes         .... 

In  the  fold  between  the  scrotum  and  thigh 

At  the  nasal  orifice      .... 

On  the  posterior  wall  of  the  pharynx 

At  the  base  of  the  toe-nails 
"     "  meatus  urinarius 

In  the  axilla        ..... 

Upon  the  gums  ..... 

Covering  the  thighs  in  an  infant  three  moi; 


were  found — • 


ths  old 

In  186  women  observed  by  Davasse  and  Deville,  muco 
found — 


110  times. 

100  " 

66  " 

55  " 

28  " 

27  " 

18  " 

17  " 

11  '■ 

11  " 

5  " 

2  " 

2  " 

2  " 

once. 


patches  were 


Upon  the  vulva      .........  174  times. 

"       "     anus 5!)       " 

"       "     periUcTum       ........  40       " 

"       "     nates  and  upper  and  inner  parts  of  the  thighs       .  38       " 

"       "     tonsils 1!)       " 


"       "     nostrils  . 

"       "     tongue    . 

"       "     toes 

"       "     face 

"       "     iimliilicus 
Around  the  nails    . 
Upon  the  ears 

"      "     soft  palate 

"      "     inguinal  fold 
'"       "     neck 

"       "     nii)ple     . 

"      "     cervix  uteri 


586  AFFECTIONS    OF    MUCOUS    MEMBRANES. 

It  thus  appears  tluit  the  most  frequent  seat  of  mucous  patches  in  men  is 
around  the  anus  and  within  the  mouth,  and  in  women  upon  the  vulva.  It 
lias  been  asserted  that  they  are  much  more  frequent  in  the  latter  than  in 
the  former  sex,  but  the  difference  is  probably  not  so  great  as  has  been 
supposed.  There  is  certainly  no  more  common  symptom  in  male  patients 
affected  with  syphilis.  They  are  also  present  in  most  cases  of  hereditary 
syphilis  in  infants,  and,  in  consequence  of  the  moist  condition  of  the  integu- 
ment at  this  early  age,  are  not  confined  to  the  regions  above  mentioned, 
but  may  be  scattered  over  the  whole  surface  of  the  body,  and  especially 
the  nates  and  thighs. 

The  development  of  mucous  patches  is  everywhere  favored  by  inatten- 
tion to  cleanliness,  and  in  the  mouth  by  the  use  of  tobacco,  either  by 
smoking  or  chewing  ;  in  men  who  are  habituated  to  this  practice,  they 
constitute  one  of  the  most  persistent  and  troublesome  symptoms  we  have 
to  deal  with,  and  in  dirty  prostitutes  of  the  lower  class  they  are  equally 
abundant  and  obstinate  about  the  genital  organs. 

Mucous  patches  vary  in  appearance  according  to  their  situation.  The 
chief  points  of  difference  are  found  between  those  seated  upon  the  external 
integument  and  those  upon  membranes  which  are  strictly  mucous. 

The  former,  which  are  met  with  for  the  most  part  around  the  anus  and 
genital  organs  in  the  two  sexes,  consist  of  rounded  disks,  either  single  or 
aggregated,  of  a  reddish  or  grayish  color,  granulated  and  elevated  to  the 
height  of  about  a  line  above  the  integument  upon  which  they  appear  to  be 
superimposed,  like  a  number  of  cones  laid  upon  the  part.  They  then 
receive  the  name  of  condylomata.  Their  appearance  is  so  peculiar,  that 
when  once  seen  it  cannot  be  forgotten. 

Their  mode  of  development  is  as  follows  :  A  red  spot  first  appears  upon 
the  skin,  and  a  slight  effusion  takes  place  beneath  the  epidermis — sufficient 
to  loosen  it  from  the  derma  but  not  to  raise  it  in  the  form  of  a  vesicle  or 
bulla;  the  epidermis  is  removed  by  friction,  or  falls  off,  and  exposes  a  raw 
surface  upon  which  a  moist,  grayish  pellicle  is  formed  ;  the  surface  ,is 
elevated  by  hypertrophy  of  the  superficial  layers  of  the  skin  and  gives  rise 
to  the  broad,  flat,  wart-like  disks  above  referred  to. 

In  Fig.  119  we  have  a  representation  of  exuberant  condylomata  situated 
around  the  vulva. 

Another  and  a  very  singular  mode  of  origin  of  mucous  patches  is  from 
the  surface  of  a  chancre,  which,  during  the  reparative  process,  may 
granulate  above  the  surrounding  integument,  and  become  covered  with  a 
thin,  translucent,  and  grayish  pellicle.  This  transformation  of  a  primary 
into  a  secondary  sym[)tom  has  already  been  described  in  the  chapter  upon 
chancre.  It  occurs  most  frequently  upon  the  genital  organs,  but  Basse- 
reau  relates  an  interesting  case  in  which  it  took  place  upon  the  lower  lip,^ 
and  I  have  met  with  an  instance  upon  the  upper  eyelid. 

When  originating  from  a  chancre,  mucous  patches  are  seated  upon  an 
indurated  base,  but  otherwise  the  tissues  beneath  them  are  found  on  pres- 

•  Op.  cit.,  p.  320. 


MIJCOUS    PATCHES.  58T 

sure  to  retain  their  normal  suppleness.  Contrary  to  the  statements  of 
some  authors,  they  never  present  the  copper  color  of  other  syphilitic 
eruptions,  but  are  either  of  a  reddish  or  grayisli -white  color.  If  the 
patient  happen  to  be  jaundiced,  the  pellicle  covering  them  may  be  tinged 
with  yellow.     They  are  usually  smeared  with  a  very  otiensive  muciform 

Fig.  119. 


Vegetating  condylomata  about  the  vulva.     (.lullien,  after  a  cast  in  the  museum  of  the  Hopital 

Saint-Louis.) 

secretion,  which  is  peculiarly  unpleasant  when  the  patches  are  seated  in 
the  neighborhood  of  the  genitals,  and  1  liave  repeatedly  known  the  odor 
to  be  so  strong  as  to  pervade  the  room.  In  a  few  exceptional  instances 
the  patches  are  dry. 

Mucous  patches  readily  become  ulcerated.  When  exposed  to  friction 
against  the  clothes  or  the  opposed  integument,  the  pellicle  covering  the 
patch  is  removed,  and  a  red,  superficial,  but  depressed  ulceration  takes  the 
place  of  the  elevated  disk.  Such  is  the  origin  of  the  raw  surfaces  fre- 
quently seen  upon  the  sides  and  front  of  the  scrotum  in  syphilitic  patients. 

Ulcerated  mucous  patches  upon  the  margin  of  the  anus  closely  resemble 
ordinary  anal  fissures,  from  which  they  may  be  distinguished  by  their 
more  prominent  and  rounded  edges,  and  by  the  grayisli  pellicle  which  is 
generally  visible  upon  tlie  sides  of  the  cleft.  When  situated  between  the 
toes,  they  yield  a  tliin,  brownisli,  and  very  oftensive  discliarge,  and  they 
often  project  upon  the  dorsum  or  palmar  surface  of  the  foot  in  tiie  form  of 
a  crescent  at  the  base  of  the  interdigital  sulci.  Ulcerated  and  fi.>^sured 
mucous  patches  upon  the  margin  of  the  anus,  between  the  toes,  or  else- 
wliere,  are  called  rhagades. 

Condylomata  upon  the  vulva  are  generally  elevated  and  of  u  reddish 
color,  TVS  is  well  represented  in  Ricord's  Iconographie,  PI.  XX.  Those 
that  I  have  seen  within  the  vagina  and  upon  the  cervix  uteri,  have  more 


588  AFFECTIONS    OF    MUCOUS    MEMBRANES. 

closely  resembled  mucous  putchcs  upon  the  external  integument  than  those 
situated  upon  other 'mucous  membranes,  as,  for  instance,  within  the  buccal 
cavity.  jNIucous  patches  upon  tlie  genital  organs  in  both  sexes  sometimes 
give  rise  to  a  discharge  resembling  gonorrhoea  from  the  neighboring  mu- 
cous membrane,  which  is  not  unfrequently  observed  about  the  time  that 
early  secondary  symptoms  appear,  or  when  a  I'elapse  of  general  symptoms 
takes  place. 

Unlike  most  syphilitic  eruptions  mucous  patches  are  frequently  attended 
by  pruritus,  especially  when  seated  ujion  the  scrotum  or  perinaeum,  and 
when  proper  attention  is  not  paid  to  cleanliness  or  the  parts  have  become 
Avarm  and  moist  from  exercise  or  prolonged  contact  in  bed.  The  unques- 
tionably contagious  character  of  these  lesions  has  previously  been  men- 
tioned. 

Mucous  patches  within  the  buccal  cavity  present  a  somewhat  different 
appearance  from  those  now  described.  Their  most  characteristic  feature 
is  the  grayish-white  color,  appearing  as  if  they  had  been  pencilled  over 
with  a  crayon  of  nitrate  of  silver,  which  has  given  them  the  name  of  "opa- 
line patches."  They  are  more  irregular  in  their  outline  than  condylo- 
mata, and  unlike  the  latter  are  not,  as  a  genei-al  rule,  perceptibly  elevated 
above  the  surface.  In  some  cases,  the  adventitious  deposit  which  gives 
them  their  grayish  color  and  which  is  with  difficulty  removed,  is  confined 
to  the  irregular  margin  of  the  patch,  while  the  centre  remains  sound  ;  and 
when  presenting  this  appearance  they  have  been  compared  to  the  track  of 
a  snail.' 

The  most  frequent  seat  of  this  form  of  mucous  patches  is  upon  the  in- 
ternal surface  of  the  lips  and  cheeks,  upon  the  sides'  and  dorsum  of  the 
tongue,  upon  the  gums,  tonsils,  and  soft  palate.  Tiiey  sometimes  extend 
beyond  the  pillars  of  the  fauces,  and  are  seen  upon  the  walls  of  the  pharynx 
and  the  posterior  nares.  Since  the  invention  of  the  laryngoscope  they 
have  also  been  seen  upon  the  epiglottis  and  mucous  membrane  of  the 
larynx. 

A  frequent  situation  is  at  the  angle  of  the  mouth,  where  they  are  often 
intersected  by  cracks  and  fissui-es,  the  sides  of  which  present  the  charac- 
teristic grayish  color  of  this  lesion,  and  where  they  are  continuous  with 
small  patclies  of  impetigo  upon  the  external  integument.  Upon  the  dor- 
sum of  the  tongue,  their  base  is  sometimes  hard,  indurated,  and  fissured  ; 
or  the  pellicle  which  at  first  covers  them  may  be  rubbed  off  by  the  food, 
leaving  a  slightly  depressed  surface  resembling  an  aphthous  ulceration  ; 
or,  again,  they  may  granulate  above  the  surface  and  form  vegetations. 
Wh(!in  seated  upon  the  tonsils,  mucous  patches  are  peculiarly  exposed  to 
irritation  and  ulceration  from  friction  of  the  food  in  deglutition,  and  ulcers 
are  formed,  attended  by  considerable  inflammation  and  swelling  of  the 
surrounding  parts,  and  in  which  the  characters  of  the  original  lesion  are 
entirely  lost.  Deglutition  is  very  much  impeded,  and  the  surrounding  in- 
inflammation  may  extend  to  the  Eustacliian  tube  and  produce  partial 
deafness. 

'  Iconographic,  pi.  XX,  bis. 


MUCOUS    PATCHES. 


589 


Bassercau  states  that  mucous  patches  may  react  upon  the  neighboriiior 
lymphatic  ganglia,  in  the  same  manner  as  syphilitic  eruptions  situated 
upon  the  scalp,  but  only  in  case  their  development  is  attended  b}-  acute 
inflammation.  Thus  the  submaxillary  glands  are  frequently  swollen  from 
sympathy  with  mucous  patches  upon  the  fauces ;  and  the  inguinal  glands 
may  be  enlarged  in  consequence  of  the  presence  of  condylomata  upon  the 
scrotum,  but  the  effect  upon  the  latter  is  less  readily  perceived  because 
they  are  generally  indurated  from  their  anatomical  connection  with  the 
primary  sore.  In  two  cases  observed  by  Bassereau,  in  which  the  chancre 
was  situated  at  a  distance  from  the  genital  organs,  the  inguinal  "lands 
were  enlarged  in  consequence  of  mucous  patches  in  the  last  mentioned 
situation.  This  effect  upon  the  ganglia  is,  however,  exceptional,  and 
always  consists  of  mere  engorgement  and  never  of  induration. 

The  following  tables  from  the  same  author  exhibit  the  period  of  devel- 
opment of  this  lesion  after  contagion  when  no  treatment  had  been  insti- 
tuted, and  also  when  mercury  had  been  given  for  the  primary  sore: 

In  the  former  case,  mucous  patches  appeared — 

On  the  20th  day  after  contagion  in    . 

"       29th      '"  "  "  ... 

From  1  to  2  months  after  contagion  in  . 

"    2  "  3        "  "  •''  ... 

"    3  "  4        "  "  "  ... 

"    5  "  G        "  "  "  .         .         , 

In  the  latter  case — 

From  2  to    3  months  after  contagion  in    . 


3  ' 

'     4 

4  ' 

'     5 

5  ' 

'     6 

a  ' 

'     7 

7  ' 

'     8 

8  ' 

'  12 

2  ' 

'  18 

1  instance. 

1 

25  instances 

5 

7 

5 

3 

2  instances 

(i 

5 

5 

6 

2 

I  will  again  remind  the  reader  that  these  dates  have  reference  to  the 
first  development  of  the  eruption  only.  The  difference  in  the  two  tables 
shows  the  power  possessed  by  mercury  to  delay  tlie  appearance  of  second- 
ary symptoms. 

Mucous  patches  are  exceedingly  chronic  and  persistent,  and  are  very 
prone  to  reapi)ear ;  they  are,  indeed,  the  most  frequent  evidence  of  the 
renewed  activity  of  the  syphilitic  poison. 

Tkkatmknt — In  addition  to  the  general  treatment  by  mercury  which 
mucous  patches  require  in  consequence  of  the  indication  they  afford  of  the 
existence  of  syphilitic  intoxication,  certain  local  applications  are  advisable. 
In  the  case  of  condylomata,  Uicord's  favorite  tniatment,  which  consists  in 
washing  them  twice  a  day  with  Lal)arraque's  solution  of  chlorinated  soda, 
then  sprinkling  them  with  calomel  and  separating  the  opposed  surfaces  by 
the  interposition  of  lint,  is  generally  very  successful,  but  it  is  sometimes 


590  AFFECTIOXS    OF    MUCOUS    MEMBRANES. 

necessary  to  destroy  tlieni  witli  nitrate  of  silver,  nitric  acid,  or  the  acid 
nitrate  of"  mercury. 

Mr.  Victor  de  Meric  speaks  highly  of  an  ointment  employed  by  several 
physicians  of  the  German  Hospital,  London,  consisting  of  two  drachms 
(8.00)  of  calomel,  the  same  quantity  of  sulphate  or  oxide  of  zinc  (it  matters 
not  which),  and  one  ounce  (30.00)  of  lard.  After  a  few  applications,  the 
excrescences  become  dry  and  horny,  fall  otF  and  leave  a  raw  surface  which 
soon  heals.  When  there  is  much  inflammation  present,  the  application  of 
poultices  should  precede  this  treatment.^ 

Mucous  patches  in  the  mouth  should  be  touched  with  nitrate  of  silver 
or  one  of  the  stronger  caustics,  and  other  applications  may  be  employed 
which  will  be  mentioned  in  a  subsecjuent  chapter.  Tiiis  local  treatment 
should  by  no  means  be  neglected,  since  without  it  these  lesions  will  often 
persist  in  spite  of  the  use  of  remedies  directed  to  the  cause  of  the  disease. 

Aubert  and  Cheron  claim  that  the  treatment  of  obstinate  cases  of  condy- 
lomata may  be  greatly  shortened  by  tirst  i)encilling  them  with  the  stick 
nitrate  of  silver  and  then  ap[)lying  to  the  surl'ace  a  piece  of  zinc.  This 
method  is  based  upon  the  decomposition  of  the  nitrate  of  silver,  and  the 
formation  of  a  nitrate  of  zinc,  which  is  a  very  powerful  caustic,  especially 
in  the  nascent  state.  This  mode  of  treatment  usually  excites  very  con- 
si  dei'able  pain. 

'  Lettsomian  Lectui-es,  p.  42. 


AFFECTIONS    OF    THE    MOUTH.  591 


CHAPTER   XVI. 

AFFECTIOXS   OF   THE   ORGANS  OF    DIGESTION. 

The  Mouth. 

Erythe^ia — Erythema  of  tlie  buccal  cavity  is  usually  confined  to  the 
neighborhood  of  the  fauces.  It  may  readily  be  confounded  Avith  the  effects 
of  an  ordinary  cold,  from  which  it  often  can  be  distinguished  only  by  the 
history  of  the  case.  The  presence  of  narrow,  dusky-red  lands  of  inflam- 
mation along  the  border  of  the  velum  ending  abruptly  at  tlie  base  of  the 
uvula  is  considered  by  some  observers  to  be  characteristic  of  syphilitic 
erythema.  Associated  with  this  condition,  as  well  as  with  other  lesions, 
there  is  often  a  general  ojdema,  especially  of  the  velum  and  uvula.  The 
latter  organ  may  become  much  swollen,  but  no  portion  of  it  should  be 
removed,  since  under  treatment  it  soon  resumes  its  normal  proportions. 
Tlie  uvula  also  may  be  completely  or  partially  eroded  by  ulceration.  In 
the  latter  case,  even  when  its  attachment  to  the  soft  palate  is  very  slender, 
the  uvula  need  not  be  excised,  since  during  the  process  of  repair  adhesions 
form  between  the  eroded  surfaces.  In  this  way  the  natural  conformation 
of  tlie  parts  may  be  restored  to  a  remarkable  degree. 

Mucous  Patches The  most  common  syphilitic  lesions  of  the  mouth 

are  mucous  patches.  They  are  most  frequently  found  upon  the  tonsils, 
the  uvula,  the  velum  palati  and  its  pillars,  the  sides  of  the  tongue  and  the 
mucous  surfaces  of  the  lips,  especially  the  lower.  At  the  angles  of  the 
mouth  tliey  are  often  continuous  witli  a  pustular  eruption  u[)ou  the  integu- 
ment. The  inner  surface  of  the  cheek  near  the  last  molar  tooth  is  anotlier 
favorite  seat.  The  dorsum  of  the  tongue  and  the  gums  are  less  fi'equently 
affected. 

Pai'Iles  axd  Vesicles — Papules  are  often  seen  in  the  mouth  coinci- 
dently  witii  a  general  papular  eruption.  Owing  to  the  constant  maceration 
of  the  mucous  membrane  of  the  mouth,  the  formation  of  vesicles  is  rare  if 
not  impossible. 

The  name  ^'"plaques  des  fnmeiirs  "  has  been  given  to  certain  patclies 
most  frequently  seen  on  the  mucous  lining  of  the  cheeks  near  tlie  angles 
of  the  moutli.  Fournier'  considers  their  location  absolutely  diagnostic, 
and,  in  view  of  their  situation  and  color,  he  lias  called  them  "  plaques 
nacrees  conii/ii'ssifraires."      Tiiey  occur  most  frecjuently  in   the  mouths  of 

'  Des  glossites  tertiaires,  Paris,  1877,  p.  54. 


592  AFFECTIONS    OF    THE    ORGANS    OF    DIGESTION. 

inveterate  smokers,  and  are  due  to  accumulation  of  the  epithelium,  which 
becomes  opaline,  as  though  the  spots  had  been  touched  with  collodion,  or 
with  nitrate  of  silver;  the  patches  are  sometimes  fissured  and  may  become 
eroded,  although  the  epithelium  is  usually  very  adherent.  They  are 
generally  quite  obstinate  and  persist  long  after  the  a[)parent  extinction  of 
the  specific  virus. 

The  Tongue. 

The  tongue  is  the  seat  of  many  interesting  and  important  lesions  of 
syphilis,  whose  I'esemblance  to  each  other  aud  to  certain  non-specific  affec- 
tions may  be  somewhat  confusing.  The  rarity  of  other  secondary  affections 
of  the  tongue  has  led  to  the  inclusion  of  many  of  them  under  the  term 
"  mucous  patch."  A  single  case  of  roseola  is  referred  to  by  Jullien^  as 
having  been  seen  by  Hardy  in  a  patient  who  had  at  the  same  time  a 
general  erythematous  eruption.  Zeissl  describes  mucous  papules  of  the 
tongue,  and  says  of  mucous  membranes  in  general  that  syphilis  does  not 
develop  pustules  in  their  structure. 

Secondary  lesions  of  the  tongue  are,  as  a  rule,  the  source  of  but  slight 
pain  at  their  inception,  and  even  in  process  of  ulceration  they  may  give 
rise  to  remarkably  little  inconvenience,  unless  subjected  to  irritation.  In 
extreme  cases  there  may  be  some  difficulty  in  mastication  and  moderate 
increase  in  the  secretion  of  saliva.  The  tendency  to  assume  the  circular 
form  has  been  observed  in  some  of  these  lesions  of  the  tongue.  They 
generally  yield  readily  to  treatment  and  leave  no  trace  of  their  existence, 
but  frequent  recurrences,  especially  in  smokers,  are  seen.  The  compara- 
tively greater  frequency  of  these  lesions  in  men  may  be  referred  to  the  use 
of  tobacco  and  alcohol,  irritating  causes  to  which  women  are  thought  to  be 
less  exposed. 

A  condition  of  so-called  ^^ psoriasis  of  the  tongtie"  has  been  described 
by  several  writers,  particularly  Bazin,^  Debove,*  and  iMauriac,*  the  syphi- 
litic origin  of  which  is  doubtful.  It  occurs  on  the  dorsum  of  the  tongue 
in  patches,  which  may  be  recognized  by  their  silvery  white  color,  their 
leathery  consistence,  and  the  epithelial  exfoliation  attending  them.  Four- 
nier,  Trelat,  Fairlie  Clarke,  and  others  regard  them  as  frequent  antece- 
dents of  epithelioma.  Clarke  thinks  that  they  assume  a  malignant 
character  when  they  invade  the  papillae  and  the  submucous  tissues.  A 
similar  affection,  originally  described  by  Samuel  Plumbe,*  under  the  name 
"  ichthyosis"  occurs  very  rarely  in  the  course  of  syphilis.  In  1875,  Weir" 
reported  ten  cases  of  ichthyosis  in  addition  to  fifty-eight  previously  recorded 
by  other  authorities.     The  proportion  of  syphilitic  subjects  in  whom  this 

'  Mai.  veneriennes,  Paris,  1879,  p.  737. 

2  Le9ons  sur  les  affections  artliritiques  et  dartreuses,  18G8. 

'  Le  psoriasis  buccal,  1873. 

*  Du  psoriasis  de  la  laiigue,  etc.,  1875. 

5  Diseases  of  the  Skin,  London,  1837,  p.  514. 

6  Ichthyosis  of  the  Tongue  and  Vulva,  N.  York  M.  J.,  Mar.  1875. 


AFFECTIONS    OP    THE    TONGUE.  593 

lesion  has  been  observed  is  extremely  small.  The  idea  that  ichtliyosis, 
psoriasis  and  the  condition  called  plaques  des  fumenrs  ai-e  identical  lesions, 
has  been  advocated  by  Hugonneau,^  who  believes  that  they  are  due  to 
different  causes,  not  necessarily  specific,  and  that  they  may  develop  into 
cancer.  Their  resistance  in  many  cases  to  anti-syphilitic  treatment,  and 
their  frequent  occurrence  in  those  who  never  present  any  evidence  of 
syphilitic  infection,  create  a  doubt  whether  these  lesions  should  be  con- 
sidered truly  specific,  although  syphilis  may  furnish  a  predisposition  to 
their  development. 

The  term  "  gummata"  was  applied  to  all  tertiary  syphilides  of  the 
tongue  until  Fournier^  classified  them  as  "  scleroses"  and  "  gummata."  In 
either  case  hyperplasia  is  the  morbid  process,  but  in  scleroses  the  newly- 
formed  cells  persist  and  become  organized  in  a  definite  manner,  while  in 
gummata  they  are  eliminated  by  a  degenerative  process. 

Sclerosis — Sclerosis  of  the  tongue  is  most  frequent  about  the  fifth 
year  of  syphilis.  It  is  usually  developed  near  the  median  line  and  always 
on  the  upper  surface  of  the  tongue,  and  may  be  superficial  or  deep. 

Superficial  sclerosis  involves  the  mucous  membrane  only,  and  produces 
a  lamellated  induration  analogous  to  the  "  parchment"  induration  of  the 
chancre.  It  may  be  circumscribed  or  ditFuse,  and  ulcerates  only  as  a 
result  of  injury  by  the  teeth,  tobacco,  or  similar  irritants. 

Parenchymatous  or  deep  sclerosis  may  be  considered  an  aggravated  form 
of  the  superficial  lesion,  and  invades  the  muscular  as  well  as  the  mucous 
tissue.  The  tongue  may  be  greatly  increased  in  size,  but  after  long  per- 
sistence of  the  lesion  the  newly-formed  fibrous  tissue  retracts,  and,  as  in 
cirrhosis  of  other  organs,  atrophy  results.  At  first  the  hypertrophied 
tongue  receives  the  imprint  of  the  teeth  at  its  margin,  the  body  of  the 
organ  being  lobulated  in  a  manner  almost  pathognomonic.  The  lobules 
are  separated  by  furrows  which  cannot  be  effaced  by  stretching,  in  this 
respect  otfering  a  contrast  with  the  rugae  which  occur  on  the  tongue  in 
dyspepsia  and  other  depraved  conditions  of  the  system.  The  induration  is 
deep  and  cartilaginous,  and  the  mucous  membrane  becomes  changed  in 
color  and  perfectly  smooth.  Ulceration  may  result  from  causes  similar  to 
those  which  produce  it  in  the  milder  fonn  of  sclerosis.  When  parenchy- 
matous sclerosis  involves  the  whole  tongue,  which  fortunately  it  seldom 
does,  the  tumefaction  may  be  enormous. 

Gummata — Like  scleroses,  gummata,  which  are  later  lesions,  may  be 
designated  as  superficial  or  parenchymatous,  since  they  may  be  found  in 
the  mucous  or  the  muscular  tissue  of  the  tongue.  The  superficial  or  mu- 
cous gumma  begins  as  a  small  nodule,  which  soon  softens  and  ulcerates,  leav- 
ing an  excavation  with  perpendicular  margins  and  an  infiltrated  base,  which 
is  often  covered  by  tenacious  false  membrane  of  a  yellowish-white  color. 

■  Sur  la  glossile  interstitielle  syphilitique,  Paris,  1876. 
*  Des  glossites  tertiaires,  Paris,  1877. 
38 


594  AFFECTIONS    OF    THE    ORGANS    OF    DIGESTION, 

Parenchymatous  gumniata  are  developed  in  the  muscular  tissue  of  the 
tongue.^  They  begin  as  small  tumors,  which  are  sometimes  difficult  of 
detection  on  account  of  their  depth  and  of  the  surrounding  induration. 
The  process  of  degeneration  extends  from  the  middle  of  the  tumors  until 
the  thinned  mucous  membrane  over  them  on  the  upper  surface  of  the 
tongue  becomes  ruptured,  exposing  a  deep  cavity  with  over-hanging  and 
sloughy  walls,  surrounded  by  an  areola  of  induration.  In  view  of  the 
great  size  of  the  cavity,  one  would  expect  excessive  deformity,  but  cicatri- 
zation often  takes  place  with  relatively  slight  permanent  damage.  In  rare 
cases  two  or  more  gummatous  tumors  coalesce,  and  lead  to  enormous 
enlargement  of  the  tongue  and  proportionate  destruction  of  its  tissue. 
The  ulcers  may  be  attacked  by  phagedtena,  when  the  condition  becomes 
still  more  aggravated.  Without  treatment  these  ulcers  are  remarkably 
chronic.  One  has  been  reported  which  persisted,  with  comparatively 
little  change,  for  twenty  years.  According  to  Clarke^  gummatous  tumors 
occasionally  undergo  calcific  degeneration. 

The  importance  and  oftentimes  the  difficulty  of  differentiating  syphilitic 
tumors  of  the  tongue  from  others  of  non-specific  origin,  especially  cancer- 
ous, are  very  great.  Boyer,  Clarke,  Lagneau,  and  many  other  authorities 
have  given  great  diagnostic  value  to  their  situation  at  the  base  and  near 
the  median  line  of  the  tongue.  The  experience  of  Fournier,  however, 
has  led  him  to  conclusions  quite  the  reverse.  Their  insidious  formation, 
their  chronic  course,  and  their  freedom  generally  from  spontaneous  pain 
are  characteristic  features  of  gummatous  tumors.  The  observation  of 
Anger^  that  lancinating  pain  shooting  towards  the  ear  is  diagnostic  of  can- 
cer of  the  tongue  has  been  repeatedly  confirmed.  Gummatous  tumors 
may  appear  at  a  period  much  earlier  than  is  usual  with  cancerous.  In 
addition  to  these  facts,  and  to  the  individual  and  family  antecedents  of  a 
patient,  the  ulcerating  surfaces  of  the  tumors  present  somewhat  constant 
features,  which  may  assist  in  the  diagnosis. 

Gummatous  ulcers  are  usually  multiple,  bilateral,  and  are  always  upon 
the  upper  surface  of  the  tongue  ;  cancerous  ulcei's  are  usually  single,  and 
may  occupy  its  under  surface.  The  ulcerative  process  of  gummata  destroys 
the  tumor;  carcinomata  present  an  ulcerating  tumor,  the  induration  of 
which  extends  with  the  eroding  process.  Tlie  fioor  of  a  gummatous  ulcer 
is  sometimes  sloughy  and  is  slightly  vascular  ;  that  of  a  cancerous  ulcer 
bleeds  readily,  and,  at  an  advanced  stage,  secretes  an  ichorous  pus. 
Zeissl*  gives  diagnostic  importance  to  the  fact  that  •'  sebum-like  plugs" 
may  be  pressed  from  the  mucous  membrane  in  epithelioma  of  the  tongue. 

Interference  with  the  functions  of  the  tongue  is  much  less  in  gummata 
than  in  cancer.     Ganglionic  enlargement  is  rare  in  syphilitic  lesions  of 

•  Bouissox.     Gaz.  mecl.  de  Par.,  184G,  p.  563. 

2  Diseases  of  the  Tongue,  London,  1873,  p.  147. 

3  Du  cancer  de  la  langue,  Paris,  1872,  p.  78.  See  Hugonneau,  oj>.  cit.,  x"'-  42, 
and  Foiirnier,  op.  cit.,  p.  66. 

<  Lehrbuch  der  Syphilis,  1875,  p.  210. 


NECROSIS    OF    THE    MAXILLARY    BONES.  595 

the  tongue,  with  the  exception  of  the  chancre,  wliile  in  cancer  it  always 
occurs. 

Confirmatory  evidence  may  be  furnished  by  microscopic  examination  of 
the  tumor,  and  by  the  effect  of  anti-syphilitic  treatment,  which,  in  cancer, 
is  sometimes  evidently  harmful. 

The  diagnosis  between  syphilis  and  tuberculosis  of  the  tongue  is  some- 
times difficult,  especially  in  those  cases  where  the  two  diseases  coexist,  and 
in  rare  instances  where  tubercular  deposit  takes  place  in  the  tongue  prior 
to  the  development  of  pulmonary  symptoms. 

So  many  instances  of  the  development  of  cancer  on  the  site  of  a  o-um- 
matous  ulcer  have  been  recorded  that  a  relation  between  the  two  affections 
cannot  be  doubted,  although  the  accident  is  not  peculiar  to  syphilitic 
lesions,  a  similar  transformation  being  observed  in  a  simple  ulcer  as  a 
result  of  neglect  or  exposure  to  continual  irritation. 

Sub-lingual  Gland. 

In  1874  Fournier^  reported  a  case  of  "tertiary  degeneration"  of  the 
sublingual  gland,  in  a  man  aged  30,  which  was  developed  eleven  years 
after  primary  infection.  The  right  sublingual  fossa  was  occupied  by  an 
oval  tumor,  quite  hard  and  painless,  which  merely  gave  slight  trouble  in 
swallowing  and  in  articulation  of  certain  words,  the  patient  speakino-  "  as 
though  he  had  a  foreign  body  in  his  mouth." 

Fournier  was  uncertain  whether  the  tumor  was  a  gummous  infiltration 
of  the  gland,  or  a  form  of  hyperplasia  analogous  to  that  of  syphilitic  sar- 
cocele.  His  belief  in  its  syphilitic  origin  seems  to  have  been  confirmed 
by  its  rapid  disappearance  under  treatment  with  the  iodide  of  potasli,  and 
by  the  subsequent  appearance  of  other  lesions  unquestionably  syphilitic. 

Necrosis  op  the  Maxillary  Bones. 

This  affection  is  most  frequently  met  with  in  the  hard  palate  and  in  the 
alveolar  processes  of  the  superior  maxillary  bone.  In  the  former  case,  a 
swelling  first  appears  upon  the  roof  of  the  mouth,  usually  near  the  median 
line  ;  softening  takes  place ;  tlie  abscess  opens,  and  the  necrosed  bone  is 
exposed.  After  evolution  of  the  sequestrum,  an  opening  is  left  communi- 
cating between  the  buccal  and  nasal  cavities,  wliich  imparts  to  the  voice 
a  nasal  sound  and  intei'feres  seriously  with  the  distinctness  of  speech  and 
with  deglutition.  When  the  progress  of  the  disease  has  been  arrested  by 
internal  treatment,  and  the  ulceration  has  healed,  the  question  not  unfre- 
quently  arises  whether  an  attempt  should  be  made  to  close  these  openings 
by  a  plastic  operation.  I  have  never  felt  disposed  to  make  the  trial,  be- 
lieving as  I  do,  that  the  wearing  of  a  plate  will  better  and  more  surely 
accomplish  the  desired  end. 

Necrosis  of  the  alveolar  processes  almost  invariably  takes  place  in  tlie 

•  Ann.  de  derm,  et  syplu,  Par.  t.  vii.  p.  81. 


596  AFFECTIONS    OF    THE    ORGANS    OF    DIGESTION. 

neighborliood  of  the  upper  central  incisors;  indeed,  I  cannot  recollect  a 
case  in  which  the  lower  jaw  was  affected.  The  bony  support  of  a  number 
of  the  teeth  is  often  involved,  and  the  teeth  themselves,  of  course,  become 
loosened  and  detached.  An  opening  not  infrequently  is  formed  into  the 
nasal  cavities,  affecting  speech  in  the  manner  above  mentioned. 

In  the  treatment  of  these  cases  the  mixed  method  affords  the  best  results, 
but,  after  the  arrest  of  the  disease,  time  is  required  for  the  sequestra  to 
become  sufficiently  detached  for  removal.  Fortunately  the  present  ad- 
vanced state  of  dental  surgery  can,  in  most  cases,  remedy  the  damage 
done. 

Gummy  Tumor  of  the  Soft  Palate. 

In  its  insidiousness  of  approach,  and  in  the  irreparable  injury  it  is  likely 
to  inflict,  but  few  syphilitic  lesions  equal  this. 

Early  symptoms  are  insignificant  or  entirely  wanting.  Possibly  the 
patient  notices  a  slight  uneasy  or  tickling  sensation  in  the  fauces,  and 
experiences  some  difficulty  in  deglutition,  which  he  naturally  attributes  to 
an  ordinary  cold ;  he  may  even  find  when  attempting  to  swallow  liquids 
that  they  regui'gitate  through  the  nostrils,  but  this  lie  regards  as  accidental. 
Suddenly,  however,  and  without  further  warning,  he  is  nearly  deprived  of 
the  power  of  speech  and  deglutition.  His  voice  is  transformed  to  an  almost 
unintelligible  nasal  whisper,  and,  upon  attempting  to  eat,  solids,  and  espe- 
cially liquids,  ai"e  returned  through  the  nose. 

If  we  are  so  fortunate  as  to  observe  this  affection  in  its  earliest  stage, 
we  find  that  it  has  two  modes  of  commencing. 

1st.  A  deposit  of  gummy  material  may  take  place  in  a  circumscribed 
mass,  within  the  substance  of  the  soft  palate,  and  between  its  buccal  and 
nasal  surfaces.  This  mode  of  origin  is  the  one  usually  described  by  authors. 
The  deposit  then  appears  as  a  flattened  tumor,  of  the  size  of  a  bean  or 
almond,  enci'oaching  upon  the  cavity  of  the  mouth.  It  is  at  first  hard,  to 
the  touch,  but  subsequently,  when  secondary  degeneration  has  taken  place, 
soft  and  fluctuating. 

2d.  In  other  cases  the  infiltration  is  diffuse.  No  tumor  exists,  but  the 
velum  is  generally  thickened,  its  raucous  membrane  reddened,  and  its 
mobility  impaired,  as  is  evident  when  the  patient  attempts  to  articulate  or 
to  swallow. 

Rupture  of  the  abscess  or  ulceration  of  the  infiltrated  tissues  may  involve 
both  mucous  surfaces  or  only  one :  in  the  latter  case  it  is  usually  the  buccal ; 
a  cavity  with  sharply  cut  and  ulcerated  edges  is  then  visible  in  the  soft 
palate,  while  possibly  the  ^oice  and  the  power  of  swallowing  remain 
unimpaired.  The  destructive  process,  however,  proceeds  with  great 
rapidity,  and  complete  perforation  soon  follows,  even  when  not  at  first 
produced. 

The  perforation  may  be  limited  in  extent,  but  frequently  a  large  portion 
or  the  whole  of  the  velum  is  destroyed,  together  with  the  uvula  and  the 
pillars  of  the  fauces,   and   thus  an   immense   door  of  communication  is 


GUMMY    TUMOR    OF    THE    SOFT    PALATE.  59t 

opened  between  the  mouth  and  nose.  It  is  thus  easy  to  account  for  the 
indistinct  and  nasal  voice,  or  "duck's  voice,"  as  the  French  call  it,  of  such 
patients,  and  also  for  the  reflux  of  liquids  and  even  solids,  and  yet  the 
absence  of  pain  which  characterized  the  onset  of  the  disease  is  still  a 
remarkable  feature,  since  deglutition,  although  so  difficult,  is  attended  with 
a  merely  trifling  sensation  of  discomfort.  In  addition,  there  is  often  some 
dulness  of  hearing,  due,  doubtless,  to  the  oedema  of  the  tissues  composing 
the  walls  of  the  pharynx  and  surrounding  the  orifices  of  the  Eustachian 
tubes. 

In  time,  the  subsidence  of  the  infiltration  is  followed  by  amelioration  of 
these  symptoms.  What  remains  of  the  velum  recovers  in  a  measux-e  its 
pliability  and  renews  its  function.  Practice  also  assists  in  teaching  the 
patient  how  to  avoid  regurgitation  of  solids  and  even  fluids.  Some  im- 
provement also  takes  place  in  the  voice,  and  this  may  be  greatly  increased 
by  wearing  a  proper  plate,  or  by  the  ingenious  artificial  palate  of  India- 
rubber,  the  invention  of  Dr.  Stearns,  but  complete  restoration  of  the 
normal  voice  cannot  be  expected.  The  impairment  of  hearing  is  only 
temporary. 

It  remains  to  speak  of  a  remarkable  sequel  of  this  affection,  viz.,  the 
change  which  usually  takes  place  in  the  fauces,  as  a  consequence  of  the 
process  of  repair.  Directly  after  the  mischief  has  occurred,  the  remains 
of  the  soft  palate  are  dependent,  and  the  opening  communicating  between 
the  mouth  and  nares  is  very  large.  One  would  naturally  suppose  that  this 
condition  would  continue  or  would  even  be  aggravated  at  a  subsequent 
period,  after  cicatrization  had  taken  place.  Strange  to  say,  such  is  not 
the  course  of  events.  The  dependent  remains  of  the  palate  become  ele- 
vated, the  ulcerated  edges  contract  adhesion  with  the  ulcerated  walls  of 
the  pharynx,  and  the  opening,  which  at  first  was  simply  immense,  gradu- 
ally contracts,  until  finally  complete  atresia  is  the  result,  or,  more  fre- 
quently, a  diminutive  channel  of  communication  remains  between  the 
buccal  and  nasal  cavities,  less  in  diameter  than  the  normal  opening.^ 
Witness  many  old  syphilitic  cases  in  our  hospitals.  Attempts  to  remedy 
this  condition  by  operation  have  been  made  by  Hoppe,  Pitha,  Coulson, 
Dumreicher,  and  Paul,  but  with  very  indifferent  success. 

Cases  not  unfrequently  occur  in  which  the  surgeon  may  hesitate  to 
express  an  opinion  as  to  the  cause  of  ulceration  and  perforation  of  the  soft 
palate.  Two  causes  only  are  likely  to  produce  this  result :  syphilis  and 
scrofula,  and  the  former  by  far  more  frequently  than  the  latter. 

If  the  patient  be  an  adult  who  has  enjoyed  at  least  tolerable  health 
until  the  present  attack,  there  can  be  little  doubt  but  that  the  cause  is 
syphilis.  No  matter  if  a  syphilitic  history  is  obscure  or  even  denied. 
Admitting  the  honesty  of  the  patient,  the  primary  and  secondary  symp- 
toms may  have  been  overlooked  or  forgotten,  and  have  left  no  traces. 

'  See^an  article  by  Dr.  II.  J.  Paul  (of  Broslau)  on  "Adhesions  of  the  Velum 
Palati  to  the  Posterior  Wall  of  the  Pharynx,  following  Ulcerations."  Translated 
by  Verneuil. — Arch.  g^n.  de  m^d.,  1865. 


598  AFFECTIONS    OF    THE    ORGANS    OF    DIGESTION. 

Tertiary  lesions  often  appear  years  after  the  preceding,  and  when  least 
expected.  Then,  too,  they  come  isolated,  without  concomitant  symptoms 
to  assist  the  diagnosis. 

If  the  patient  be  young,  say  of  10  to  15  years  of  age,  the  chances  of 
syphilis  are  less,  of  scrofula  greater.  Inquire  as  to  the  evidences  of 
hereditary  taint.  When  an  infant,  was  the  child  affected  with  an  eruption, 
coryza,  etc.  ?  Look  at  the  upper  incisor  teeth  ;  are  they  well  formed  or  do 
they  show  ti'aces  of  hereditary  disease?  Are  the  corneae  clear  and  intact? 
Are  there  cicatrices  of  strumous  ulcers  upon  the  neck  or  elsewhere?  In 
all  cases  the  effect  of  treatment  is  a  valuable  aid  to  diagnosis.  Syphilitic 
ulceration  yields  to  full  doses  of  the  iodide  of  potassium  as  if  by  magic. 
Strumous  ulceration  may  be  benefited  by  the  same  remedy,  especially  if 
combined  with  tonics,  but  it  exhibits  no  such  marked  improvement  within 
a  few  days. 

The  Pharynx. 

Lesions  similar  to  those  occurring  in  the  mouth  are  met  with  in  the 
pharynx.  Erythema,  superficial  ulcers,  and  deep  ulcerations  resulting 
from  degeneration  of  gummatous  deposit  may  be  observed.  The  occur- 
rence of  mucous  patches  of  the  pharynx  has  been  noted  by  several  author- 
ities, but  we  have  never  seen  them  in  this  region.  Their  rarity  may  be 
ascribed  to  the  fact  that  the  papillae  of  the  pharyngeal  mucous  membrane 
are  of  extremely  small  size.  Frequently  ulcers  extend  into  the  pliaiynx 
from  the  posterior  nares.  The  symptoms  of  pharyngeal  syphilis  are  usually 
insignificant,  except  in  the  case  of  ulcers,  when  there  may  be  pain,  aggra- 
vated in  the  act  of  swallowing  and  especially  on  the  ingestion  of  acrid  or 
irritating  substances.  The  posterior  portion  of  the  lateral  walls  of  the 
pharynx  is  more  often  attacked  than  the  posterior  wall.  Gummy  tumors 
have  been  observed  on  tlie  vault  of  the  pharynx  and  on  the  upper  partjof 
its  posterior  wall.  After  destroying  the  mucous  membrane  the  disease 
may  even  invade  the  vertebrte  and  produce  necrosis,  or  even  iuffammation 
of  the  contents  of  the  vertebral  canal. 

Syphilitic  ulcerations  of  the  pluirynx  are  of  special  interest  on  account 
of  the  traces  which  they  leave  in  the  form  of  cicatrices,  or  of  adhesions, 
which  diminish  the  capacity  of  the  cavity  and  interfere  with  its  functions. 
The  cicatrices  seen  upon  the  pharyngeal  wall  are  quite  characteristic. 
They  may  present  a  stellate  appearance,  or  may  assume  the  form  of  pro- 
minent bands.  The  cicatricial  tissue  is  white  and  glistening,  and  may 
persist  indefinitely,  or  gradually  contract. 

In  rare  cases  the  entire  soft  palate  is  destroyed  by  ulceration,  necrosis  of 
the  hard  palate  occurs,  and  the  mouth,  the  nose,  and  the  pharynx  are  con- 
verted into  one  enormous  cavity.  In  milder  cases,  when  the  ulcerative 
process  is  limited  to  the  border  of  tbe  velum  and  the  pharyngeal  wall,  ad- 
hesions may  form,  which  divide  the  cavity  of  the  pharynx  into  two  distinct 
chambers,  one  communicating  with  the  posterior  nares  and  the  other  with 
the  mouth.     There  may  be  a  very  narrow  passage  between  these  two  cavi- 


TREATMENT    OF    LESIONS    OF    MOUTH    AND    PHARYNX.         599 

ties,  or  they  may  be  completely  shut  off  from  each  other,  respiration  being 
carried  on  exclusively  through  the  mouth. 

It  is  often  very  difficult  to  distinguish  between  the  deep  ulcerations  of 
syphilis  and  those  of  struma.  There  are  at  least  four  points  to  be  con- 
sidered in  making  a  diagnosis.  In  syphilis  other  lesions  are  usually  found. 
Syphilitic  ulcerations  follow  the  formation  of  a  gummatous  tumor ;  in  but 
few  cases,  however,  on  account  of  the  very  slight  inconvenience  occasioned 
by  even  extensive  lesions,  is  the  patient  observed  before  complete  destruc- 
tion of  the  original  gummy  tumor.  Specific  ulcers  usually  progress  more 
rapidly  than  scrofulous  u  cers  ;  and,  finally,  they  yield  to  specific  treat- 
ment. Some  observers  claim  that  the  ulcers  themselves  present  distinctive 
characteristics,  but  this  can  be  very  rarely  the  case.  The  diagnosis  must 
be  based  chiefly  on  the  antecedents  of  the  patient  and  the  history  of  the 
lesion. 

Treatment  of  Lesions  of  the  Mouth  and  Pharynx. 

The  treatment  of  syphilitic  atfections  of  the  mouth  and  pharynx  resolves 
itself  into  constitutional  and  local.  For  an  account  of  the  former  I  must 
refer  the  reader  to  the  chapter  upon  the  treatment  of  general  syphilis. 
Suffice  it  at  present  to  say  that  mucous  patches,  erythema,  and  the  super- 
ficial forms  of  ulcers  belong  to  the  secondary  stage  of  syphilis  and  require 
the  use  of  mercurials  in  accordance  with  the  directions  given  in  the  chapter 
referred  to,  while  the  deep  ulcerations  belong  to  the  tertiary  stage,  in  the 
treatment  of  wliich  the  iodide  of  potassium  plays  so  important  a  part. 

Local  treatment  is  of  great  importance.  It  is  often  surprising  to  see 
how  mucous  patches  of  the  mouth  and  fauces  will  persist  under  the  best 
directed  internal  treatment  used  alone,  and  yet  how  readily  they  will  dis- 
appear when  appro[)riate  local  treatment  is  added. 

Those  situated  upon  the  lips,  internal  surface  of  the  cheeks,  and  sides  of 
the  tongue,  should  be  touched  every  second  or  third  day  with  a  crayon  of 
nitrate  of  silver  or  the  sulphate  of  copper,  or  the  acid  nitrate  of  mercury. 
Another  excellent  application  is  the  chloride  of  gold,  adding  just  enough 
water  to  make  it  liquid,  and  applying  it  with  a  camel's-hair  brush.  With 
those  upon  the  fauces,  the  walls  of  the  pharynx,  larynx,  etc.,  I  much  pre- 
fer the  spray  of  a  saturated  solution  of  nitrate  of  silver,  applied  by  means 
of  the  atomizer  represented  in  Fig.  120. 

Other  forms  of  tlie  same  instrument  may  be  obtained,  in  which  the 
spray  is  directed  upwards  or  downwards  for  the  cauterization  of  the  pos- 
terior nares  and  the  larynx.  These  atomizers  luxve  been  much  improved 
and  perfected  by  Dr.  Louis  F.  Sass,  of  New  York,  to  whom  I  am  indebted 
for  those  in  my  possession. 

In  nearly  all  cases  of  the  ash-colored,  excavated  ulcers  upon  the  tonsils 
or  uvula,  the  stronger  caustics,  as  nitric  acid  or  the  acid  nitrate  of  mer- 
cury, must  be  employed.  In  making  these  latter  applications,  great  cau- 
tion is  required  lest  the  acid  come  in  contact  with  the  sound  tissues,  or  its 
fumes  be  inhaled;  and  these  evils  may  be  avoided  by  taking  care  that  the 


600 


AFFECTIONS    OF    THE    ORGANS    OF    DIGESTION. 


probang  or  glass  rod  which  is  employed  be  not  so  wet  as  to  permit  the 
fluid  to  drop  from  it,  and  by  allowing  the  fumes  to  pass  off  before  the 
remedy  is  applied. 


Fiff.  120. 


The  application  of  caustics  should,  however,  be  deferred  in  cases  at- 
tended by  severe  inflammation  and  swelling  of  the  fauces,  which  must  first 
be  subdued  by  saline  cathartics,  rest,  mustard  pediluvia,  and  sometimes  by 
leeches  at  the  angle  of  the  jaw.  I  have  found  the  most  grateful  topical 
application  under  these  circumstances  to  be  a  solution  of  tannin  in  glyce- 
rine (5j  to  the  §j),  with  the  addition  of  extract  of  opium  if  the  pain  be 
severe,  which  may  be  applied  with  a  camel's-hair  brush  two  or  three  tim^s 
a  day.  Rest  should  be  promoted  by  means  of  sedatives,  of  which  Dover's 
powder  is  the  best. 

So  soon  as  the"  acute  inflammation  has  subsided,  various  astringent  and 
tonic  gargles  may  be  employed  with  benefit.  A  good  one  is  the  undiluted 
tincture  of  Cimicifuga.  It  should  be  prepared  from  the  fresh  root,  as 
otherwise  the  effect  is  much  diminished.  Washes  and  gargles  containing 
Labarraque's  solution,  chlorate  of  potash,  the  bichloride  of  mercury,  or 
the  oxymel  of  the  subacetate  of  copper  also  serve  an  excellent  purpose. 


Liquor.  Sodae  ChlorinataB  5ij-3iv 

Mellis  I] 

Aquje  §v 


81—16 

38 
150 


Hydrarg.  Bicliloridi  gr.  vj 
Acidi  Hydrochlorici  gtt.  xij 

Syrupi  |j 

Aquce  §viij 


38 
250 


THE    (ESOPHAGUS.  601 

R.     Potassae  Chlorat.  5j 41 

Infusi  Lini  Oj 500| 

M. 

T^.     Oxymellis  Cupri  Subacetatis  3ij      •     •     601 

AquEe  §vj 180| 

M.  (Langston  Parker.) 

^..     Acidi  Sulphurosi  ^ss 15 

Glyceriiire  §iss 55 

Aquje  §vj 180 

M.  (Mr.  Shillitoe.) 

Either  of  the  above  washes  may  be  used  three  or  four  times  in  the 
twenty-four  hours.  In  fetid  and  phagedenic  ulcerations  of  the  throat,  the 
following  is  a  valuable  formula  : — 

]^.     Creasoti  nix 65 

Mellis  ^j 38 

Aquie  |vij 210 

M. 

In  all  syphilitic  affections  of  the  mouth  and  pharynx,  the  surgeon  must 
insist  upon  the  patient's  abstaining  from  the  use  of  tobacco,  which  is  found 
in  practice  to  be  the  most  common  cause  of  the  pei-sistency  of  these  lesions 
and  of  tlieir  frequent  return  after  removal.  Unless  this  restriction  be 
faithfully  complied  with,  the  patient  should  understand  that  little  perma- 
nent benefit  can  be  expected.  The  question  is  often  asked  whether  smok- 
ing or  chewing  is  the  more  injurious  ?  Tobacco  in  any  form  acts  as  an 
irritant,  but  in  the  act  of  smoking  a  partial  vacuum  is  produced  in  the 
mouth,  whereby  the  vessels  of  the  mucous  membrane  are  congested,  and 
I  am  therefore  inclined  to  think  smoking  the  more  injurious  of  the  two 
habits. 

The  CEsophagus. 

In  an  able  paper  by  INIr.  James  F.  West,  Surgeon  to  the  Queen's  Hos- 
pital, Birmingham,  which  was  published  in  the  DuUin  Quarterly  Journal 
of  Medical  Science  for  Feb.  IHGO,  the  probability,  if  not  the  absolute 
certainty,  that  stricture  of  the  cesophagus  may  be  due  to  syphilis  was  first 
established. 

The  case  upon  which  Mr.  AYest's  observations  were  chiefly  founded  was 
one  of  a  girl  aged  21,  who  h.ad  suffered  for  several  years  from  well-marked 
syphilitic  manifestations,  such  as  eruptions  upon  the  skin,  ash-colored 
ulcerations  of  the  fauces,  rheumatic  pains,  and  syphilitic  cachexia,  and 
who  was  admitted  into  Queen's  Hospital,  May  18,  1858,  for  stricture  of 
the  frsophagus.  Treatment  by  means  of  tonics,  iodide  of  potassium,  and 
mercurials  afforded  only  temporary  relief,  and  she  succumbed  on  Sept.  2, 
of  the  same  year.  The  following  appearances  were  found  at  the  post- 
mortem examination :  "  The  upper  portion  of  the  oesophagus  for  about 
four  iBches  was  much  dilated ;  its  mucous  membrane  thickened,  and 
marked  by  s{)Ots  having  the  apjjearance  of  recent  cicatrices.  At  this  dis- 
tance from  the  upper  end  it  was  suddenly  constricted,  and  terminated  in 


602  AFFECTIONS    OF    THE    ORGANS    OP    DIGESTION. 

a  narrow  canal  which  would  barely  admit  a  No.  4  catheter.  This  con- 
stricted portion,  which  was  about  two  inches  and  a  half  in  length,  was 
formed  by  the  thickening  of  the  mucous  membrane,  and  by  fibrous  deposit 
in  the  form  of  bands  and  bridles,  having  very  much  the  appearance  of  an 
old  stricture  of  the  urethra.  Below  this  track  the  ossophagus  continued 
perfectly  healthy  to  its  termination  in  the  stomach.  Both  lungs  contained 
tubercular  deposit  in  different  degrees  of  softening,  with  several  small 
cavities  in  the  upper  lobe  of  each,  one  in  the  left  apex  being  as  large  as  a 
pigeon's  egg." 

In  reviewing  this  case  Mr.  West  remarks:  "We  have  no  account  of 
the  swallowing  of  any  caustic  or  irritating  fluid,  so  that  we  cannot  attri- 
bute the  stricture  to  that  cause.  The  presence  of  numerous  recent  cica- 
trices clearly  indicated  that  ulcerations  had  existed  in  the  walls  of  the 
oesophagus.  The  deposit  in  the  submucous  tissue  was  fibrous  ;  it  was  ex- 
actly similar  in  nature  to  that  which  is  so  well  described  by  Dr.  AVilks  as 
characteristic  of  syphilitic  eruption,  and  could  not  under  any  supposition 
be  referred  either  to  cancerous  or  tubercular  degenei'ation." 

Mr.  West'  has  since  reported  another  case  in  which  the  pathological 
appearances  were  very  similar,  and  states  that  Mr.  Langston  Parker  has 
recently  met  with  a  case  of  general  syphilis  in  private  practice  in  which 
unmistakable  stricture  of  the  oesophagus  existed. 

In  reviewing  this  subject  it  appears  extremely  probable  that  Mr.  West 
is  right  in  his  conjecture  as  to  the  cause  of  the  stricture  in  the  cases  which 
have  come  under  his  observation,  since  we  may  readily  admit  that  syphi- 
litic ulceration  of  the  fauces  may  extend  to  tlie  oesophagus  or  attack  the 
latter  as  a  primary  affection  ;  and  yet  it  is  singular  that  this  effect  of 
syphilis  has  attracted  so  little  attention  from  previous  observers,  and  to 
the  names  of  those  authors  who  are  (|uoted  by  Mr.  West  as  silent  upon  the 
subject,  I  will  add  that  of  Yvaren,  whose  work  on  the  Metamorphoses  de 
la  syphilis  includes  nearly  all  the  obscure  forms  of  syphilitic  disease,  so 
far  as  they  are  known.  Follin,^  however,  was  of  the  opinion  that  some 
of  the  reported  cases  of  stricture  of  the  oesophagus  might  be  attributed  to 
syphilis,  and  Virchow  has  met  with  contraction  of  the  upper  portion  of 
this  tube  in  the  post-mortem  examination  of  a  syphilitic  subject.^ 

Some  of  the  cases  of  syphilitic  stricture  of  the  oesophagus,  whose  advent 
and  whose  disappearance  under  treatment  are  somewhat  sudden,  are  prob- 
ably spasmodic,  the  contraction  being  excited  by  ulceration  of  the  mucous 
membrane  of  the  canal.  Organic  strictures,  which  undoubtedly  may  result 
from  syphilis,  are  caused  by  fibrous  deposits  in  the  submucous  tissue,  thick- 
ening of  the  mucous  membrane,  and  by  contraction  of  cicatrices  following 
ulceration. 

Obviously,  anti-syphilitic  treatment  can  avail  in  cases  of  only  the  former 
class.     The  iodide  of  potassium  seems  to  have  given  relief  in  one  of  Mr. 

»  Dublin  Q.  J.  M.  Sc. 

2  Des  r6trecissem«nts  de  I'ocsophage,  Paris,  1853,  p.  30. 

8  Syphilis  constitutioiielle,  p.  88. 


STOMACH    AND    INTESTINES.  603 

West's  cases,  while  only  temporary  benefit  was  derived  from  the  use  of 
mercury. 

In  cases  of  organic  stricture,  dilatation  with  oesophageal  bougies,  com- 
bined with  general  tonic  treatment,  is  a  palliative  resource.  When  death 
from  inanition  seems  probable,  in  spite  of  rectal  alimentation  and  of  medi- 
cation, the  question  of  producing  a  gastric  fistula  arises. 

A  most  interesting  case  of  syphilitic  stricture  of  the  oesophagus  occurred 
several  years  ago  in  the  practice  of  Prof.  F.  F.  Maury,  of  Philadelphia, 
in  which  this  accomplished  surgeon  resorted  to  gastrotomy,  after  it  had 
become  impossible  for  the  smallest  quantity  of  food  or  the  finest  bougie  to 
enter  the  stomach,  and  the  patient  had  been  kept  alive  for  several  weeks 
by  way  of  the  rectum.  Unfortunately  the  operation  was  performed  too 
late,  and  the  patient  died  of  exhaustion  in  fourteen  hours  after.  The  post- 
mortem showed  a  very  tight  stricture,  entirely  free  from^  any  evidences  of 
cancer,  just  above  the  cardiac  orifice.  The  patient's  syphilitic  antecedents 
had  been  unequivocal.^ 

Mr.  Bryant  was  somewhat  more  fortunate  in  the  case  of  a  patient  at 
Guy's  Hospital  upon  whom  he  did  this  operation,^  life  being  prolonged 
until  the  fifth  day.  The  fatal  result  was  due  to  pulmonary  complication, 
which  Jullien^  believes  is  the  most  frequent  cause  of  death  in  these  cases. 

Syphilitic  gummata  have  been  found  in  the  wall  of  the  oesophagus,  and 
doubtless  obstruction  may  be  caused  by  the  growth  of  vertebral  nodes. 
Habershon*  refers  to  a  specimen,  in  the  Hunterian  Museum,  of  a  gumma- 
tous tumor  of  the  liver  which  had  produced  a  similar  result. 

Stomach  and  Intestines. 

Functional  disturbance  of  the  digestive  organs  is  not  an  uncommon 
effect  of  the  contamination  of  the  blood  by  the  syphilitic  virus,  as  shown 
by  the  loss  of  appetite  or  the  occasional  inordinate  desire  for  food,  and  the 
nausea  and  vomiting  which  sometimes  accompany  the  appearance  of  early 
secondary  manifestations.  The  general  cachexia  belonging  to  the  later 
stage  of  syphilis  may  also  be  attended  by  intestinal  derangement.  But 
the  question  is  an  interesting  one,  and  one  not  yet,  perhaps,  fully  solved, 
how  far  syphilis  may  produce,  in  those  portions  of  the  intestinal  canal 
which  are  beyond  the  reach  of  sight,  the  same  organic  changes  and  their 
consequences  which  are  known  to  exist  at  the  outlets  and  more  accessible 
portions  of  the  same  canal.  Are  syi)liilitic  erythema,  mucous  patches, 
ulcerations,  and  deposits  of  gummy  material  to  be  found  in  the  stomach 
and  intestines,  as  in  the  buccal  cavity? 

CuUerier^  believes  in  a  form  of  enteritis  developed  in  syphilitic  subjects, 

'  Am.  J.  M.  Sc,  Phila.,  April,  1870. 

'  Habersliou  on  Diseases  of  the  Abdomen,  etc.,  3d  ed.,  1878,  p.  73.  Quoted 
from  the  post-mortem  records  of  Guy's  Hospital. 

3  Mai.  ven^riennes  1879,  p.  848.  *  Op.  cit.  p.  7G. 

^  CuLLEKiER  and  Bumstead's  Atlas,  p.  2t)0. 


60t  AFFECTIONS    OF    THE    ORGANS    OF    DIGESTION. 

which  is  probably  not  ulcerous,  and  "  the  specific  nature  of  which  cannot 
be  doubted,"  and  he  is  thus  led  to  admit  syphilitic  exanthema  of  the  in- 
testines. Post-mortem  examinations,  however,  of  persons  dying  in  the 
early  secondary  stage  of  syphilis  are  rare,  so  that  the  above  statement  can 
with  difficulty  be  verified.  Moreover,  enteritis  supervening  during  this 
stage  may  be  due  to  the  improper  use  of  mercury,  or  to  many  simple  causes. 
Hence  we  must,  I  think,  regard  the  existence  of  syphilitic  erythema  of 
the  intestines  as  probable  but  not  demonstrated. 

With  regard  to  late  syphilitic  affections  of  the  stomach  and  intestines 
our  knowledge  is  more  definite.  Several  cases  have  been  reported  of 
persons  in  the  tertiary  stage  of  syphilis,  who  have  suffered  from  chi-onic 
diarrhoea  that  did  not  yield  to  simple  treatment,  and  in  whom  post-mortem 
examination  has  revealed  ulcerations  of  the  stomach  or  intestines,  identical 
in  their  appearance  with  the  ulcerations  of  gummy  deposits  on  other  mucous 
surfaces.  Cullerier  gives  such  a  case  (op.  cit.,  p.  317).  In  another 
instance,  reported  by  Lancereaux  (op.  cit.,  p.  311),  "The  stomach  was 
about  of  the  normal  size,  but,  near  the  pylorus  and  on  the  smaller  curva- 
ture there  wa.s  an  ulceration  which  had  nearly  eaten  through  the  wall  of 
this  organ  ;  its  edges  were  bevelled  at  the  expense  of  the  mucous  mem- 
brane, and  were  fibrous  and  indurated  ;  at  certain  points  they  were  of  a 
clear  grayish  color,  while  at  others  they  had  a  cicatricial  appearance.  No 
indurated  ganglia  in  the  neighborhood." 

Cornil  gives  a  case  of  gummata  of  the  stomach  associated  with  similar 
lesions  of  the  liver,  the  patient  having  died  with  pulmonary  complication. 
The  only  symptoms  were  indigestion  and  pain  in  the  epigastrium.  An 
extraordinary  case  of  multiple  gummata  of  the  parietal  and  visceral  peri- 
toneum has  been  reported  by  Laurenzi.^ 

Lancereaux  concludes  that  the  intestinal  canal  may  in  rare  cases  be  at- 
tacked by  syi)hilis,  and  that  "  the  multiple  and  rounded  ulcerations,  pene- 
trating to  a  greater  or  less  depth  and  circumscribed  by  fibrous  tissue,  of 
which  it  is  sometimes  the  seat,  are  probably  only  the  sequence  of  gummy 
deposits,  or,  in  other  words,  the  result  of  the  degeneration  which  these 
deposits  have  undergone.  The  simple  thickening  of  the  submucous  tissue 
met  with  in  some  instances,  and  the  case  reported  by  Wagner,^  of  deposits 
not  yet  ulcerated,  are  favorable  to  this  view." 

This  view  is  still  further  supported  by  the  beneficial  effect  of  the  iodide 
of  potassium  in  several  of  CuUerier's  cases,  given  either  in  large  doses  in- 
ternally, or,  when  the  stomach  was  irritable,  in  the  form  of  enemata  (gr. 
xv-lxxv  ad  aquai  .^iv-vj). 

Ths  symptoms  of  this  affection  present  nothing  peculiar  to  mark  their 
origin  aside  from  the  history  of  tlie  case  and  the  coexistence  of  well-marked 
syphilitic  lesions  elsewhere.  They  consist  only  of  an  almost  constant  and 
obstinate  diarrhoea,  sometimes  with  bloody  stools,  attended  with  a  feeling 
of  oppression  and  nialaise  in  the  abdomen,  and  occasionally  with  severe 

'  Gior.  ital.  d.  mal.  ven.,  Milano,  1871,  vol.  ii,  p.  298. 
2  Arch.  d.  Heilk.,  1863,  obs.  xxix,  p.  369. 


THE    RECTUM.  605 

colic.  There  may  also  be  frequent  eructations  and  vomiting  of  food  a  few 
hours  after  its  ingestion  ;  the  appetite  diminishes;  the  patient  loses  in 
strength  and  in  weight,  and  assumes  a  condition  of  general  cachexia,  which 
is  observed  in  syphilis  of  other  internal  organs. 

The  Rectum. 

Chancroids  situated  near  the  margin  of  the  anus  may  give  rise  to  a  form 
of  stricture  of  the  rectum,  which  has  improperly  been  called  "syphilitic." 
Its  true  pathology  was  first  pointed  out  by  M.  Gosselin,^  who  reports 
twelve  cases  under  his  own  observation,  including  three  in  which  he  was 
able  to  make  a  post-mortem  examination.  M.  Gosselin's  views  have  been 
confirmed  by  other  eminent  authorities^  as  Mr.  Holmes  Coote^  and  Lance- 
reaux.^  I  have  myself  had  several  cases  under  my  charge,  in  which  tlie 
antecedents  pointed  in  the  same  direction,  and  in  which  a  thorough  trial  of 
mercury  and  iodide  of  potassium  failed  to  afford  the  slightest  relief,  as  they 
would  have  done  if  the  trouble  had  been  of  syphilitic  origin.* 

This  lesion  depends  upon  a  thickening  or  hypertrophy  of  the  submucous 
cellular  tissue  of  the  rectum,  the  same  as  is  produced  by  chancroids  of  the 
j)repuce  and  labia  minora  in  the  neighborhood  of  their  site,  and  which  has 
already  been  described.  All  the  cases  thus  far  reported  have  occurred  in 
women,  as  may  readily  be  explained  by  the  greater  frequency  of  chancroids 
about  the  anus  in  this  sex. 

The  patients  often  complain  merely  of  a  frequent  desire  to  go  to  stool, 
which  is  followed  by  a  discharge  of  pus  and  sanguinolent  mucus.  Consti- 
pation, and  difficult  and  painful  defecation  are  present  in  only  a  few  in- 
stances ;  the  majority,  especially  when  the  disease  has  been  of  long  standing, 
suffer  from  constant  diarrhoea.  The  amount  of  purulent  discharge  is  ex- 
cessive, either  with  or  without  fecal  matter  at  stool,  or  involuntai'ily  during 
the  day.  Most  of  the  patients  lose  flesh  and  strength,  and  suflfer  from  va- 
rious dyspeptic  symptoms.  In  nearly  all,  hypertrophied  and  prominent 
folds  of  integument  ai-e  found  upon  the  margin  of  the  anus.  The  stricture 
is  invariably  found  at  the  depth  of  about  an  inch  and  a  half  or  two  inches 
from  the  margin  of  the  anus,  and  does  not  appear  to  vary  from  this  posi- 
tion like  strictures  dependent  upon  other  causes. 

The  stricture  is  composed  of  an  indurated  and  inextensible  adventitious 
•leposit  in  the  substance  of  the  mucous  membrane  and  the  submucous 
cellular  tissue.  It  is  never  impermeable  nor  so  contracted  as  entirely  to 
l)revent  the  exit  of  fecal  matter.  The  muscular  tissue  surrounding  the 
contracted  portion  is  somewhat  hyt)ertropliied.  There  is  not  the  slightest 
evidence  of  any  deposit  similar  to  that  found  in  gummy  tumors. 

'  Des  retrecissements  syphiliticjues  du  rectum,  Arch.  g§n.  de  miSd.,  t.  iv,  5«s6rie, 
]>.  fJ(J7. 

«  Med.  Times  and  Gaz.,  Lond.,  Jan.  27,  1855.  »  Op.  cit.,  p.  315. 

*  See  also  Bull.  Soc.  anat.  de  Paris,  2e  serie,  t.  iv,  1859,  p.  100 ;  also  a  paper 
read  by  the  author  of  tliia  work  l)efV)re  tlie  N.  Y.  Acad,  of  Med.,  April,  1864,  Bull. 
of  the  Acad.,  vol.  ii,  p.  280. 


GOG  AFFECTIONS    OF    THE    ORGANS    OF    DIGESTION. 

The  lining  membrane  of  the  dilated  portion  of  the  rectum  above  the 
stricture  is  denuded  of  its  epithelium  and  glandular  layer,  giving  rise  to  an 
extensive  and  continuous  erosion  for  about  four  or  five  inches  above  the 
contraction,  and  the  muscular  tissue  surrounding  this  portion  is  hypertro- 
phied.  This  ulcerated  surface  is  the  chief  source  from  which  is  d(5rived 
the  pus  that  is  mingled  wath  the  stools  and  flows  away  involuntarily. 
Gosselin  believes  that  so  extensive  an  erosion  is  peculiar  to  this  class  of 
strictures. 

Since  the  last  edition  of  this  work  much  has  been  written  upon  syphi- 
litic aflections  of  the  rectum,  but  little  has  been  added  to  our  knowledge 
of  the  subject.  The  chief  contribution  has  been  by  Fournier,^  who  has 
published  an  elaborate  brochure,  of  which  the  thesis  of  his  student,  Gode- 
bert,  is  a  reca|)itulation.  Fournier  thinks  that  tertiary  lesions  of  the  anus 
and  rectum  are  rare,  and  classifies  them  as  ulcerating  syphilides,  gummous 
syphilides,  and  a  third  variety,  wliich  he  calls  syphilome  ano-rectal.  He 
subdivides  ulcerating  syphilides  of  the  rectum  into  two  kinds ;  those  which 
are  continuous  with  ulcers  outside  the  anus,  and  extend  one  or  two  centi- 
metres, more  rarely  three  or  four  centimetres,  within  the  sphincter.  In 
one  case  they  reached  further  than  he  could  see  even  with  the  aid  of  the 
speculum ;  secondly,  those  which  are  developed  originally  within  the  rec- 
tum, as  multiple  ulcerations,  either  in  the  sigmoid  flexure  and  rectum,  or 
confined  to  the  latter  portion  of  the  intestine.  He  says  that  these  lesions 
are  very  rare,  although  they  are  [)robably  more  common  than  is  supposed, 
since  they  are  seldom  looked  for.  He  has  never  seen  gummous  infiltra- 
tion, but  it  has  been  observed  by  Prof.  Verneuil,  and  he,  therefore,  con- 
siders it  another  but  rare  cause  of  rectal  stricture.  The  third  lesion  of 
syphilis,  which  may  cause  stricture  of  the  rectum,  is  the  one  upon  which 
Fournier  lays  most  stress.  He  thinks  that  most  of  the  strictures  in  syphi- 
litic persons  are  caused  "6y  an  infiltration  of  the  ano-rectal  walls  with  a 
neoplasm  of  unknown  structure,  hut  capable  of  degenerating  into  a  fibrous 
tissue,  the  contractioti  of  which  results  in  coarctation  of  the  intestine.'"' 
In  proof  of  this  theory  he  has  no  facts  derived  from  post-mortem  examina- 
tions, but,  reasoning  from  analogy,  he  concludes  that  since  syphilis  pro- 
duces connective  tissue  hyperplasia  in  other  organs,  as  the  testes,  lungs, 
liver,  etc.,  it  may  have  a  similar  effect  in  the  rectum.  This  theory,  cer- 
tainly more  than  any  other,  seems  to  be  in  accord  with  the  facts.  Four- 
nier calls  attention  to  the  fact,  that  at  the  autopsies  of  subjects  with  old 
syphilitic  strictures  of  the  rectum,  no  ulcerations  nor  cicatrices  can  be 
found ;  hence,  he  infers  that  the  morbid  changes  are  submucous  rather 
than  in  the  mucous  membrane  itself.  He  admits,  however,  that  contrac- 
tions from  ulceration  do  occur,  but  claims  that  tliey  are  very  rare.  He 
thinks  also  that  chronic  inflammation  may  have  a  modifying  influence  in 
the  production  of  stricture. 

In  this  lesion  the  entire  circumference  of  the  rectal  wall  for  a  distance 
of  from  three  to  eight  centimetres  above  the  sphincter,  becomes  trans- 

•  Fournier,  Lesions  tertiaires  de  I'anus  et  du  rectum,  Paris,  1875. 


THE    RECTUM.  60*7 

formed  into  a  thickened,  hard,  and  unequally  rigid  cylinder,  with  no  trace 
of  ulceration.  AVhen  the  infiltration  is  limited  to  the  vicinity  of  the  anus, 
it  is  not  uniformly  ditfused  around  the  circumference  of  the  canal,  but  is 
circumscribed,  forming  tumor-like  masses,  irregularly  round  or  flattened, 
which  are  at  first  covered  by  healthy  tissue.  These  masses  are  firm  and 
elastic,  and  are  painless  unless  they  become  inflamed ;  they  are  liable  to 
erosion  and  ulceration.  These  anal  lesions  are  curable  if  treated  early, 
but  if  neglected  they  inevitably  result  in  stricture.  It  is  the  opinion  of 
Fournier  that  these  lesions  are  more  common  in  females  than  males,  in 
the  proportion  of  eight  to  one. 

We  have  given  an  analysis  of  this  valuable  paper  in  order  to  present 
clearly  the  views  of  its  accomplished  author.  While  we  agree  with  him 
in  the  main,  we  are  somewhat  surprised  that  he  is  silent  regarding  the  in- 
fluence of  chancroids  in  producing  rectal  strictures. 

The  views  of  Fournier  concerning  syphilome  ano-rectal  are  adopted  by 
Duplay,^  who  thinks,  however,  that  primary  lesions  and  gummata  are 
never  the  cause  of  rectal  stricture.  He  says,  "  the  cylindrical  and  ex- 
tended stricture  of  the  rectum  accompanied  by  thickening  and  induration 
of  the  walls  is  a  constitutional  affection,  having,  in  a  measure,  its  own 
proper  individuality."  He  thinks  that  the  irritation  to  which  the  rectum 
is  subjected  is  the  exciting  cause. 

One  of  the  most  important  contributions  to  the  subject  of  gummy  infil- 
tration of  the  rectum  is  contained  in  the  report  of  a  case  by  Zeissl.'^  The 
patient  was  a  man  who  contracted  syphilis  in  1860,  and  suffered  severely 
from  it.  Fourteen  years  later  he  came  under  Zeissl's  observation,  being 
much  emaciated,  and  having  a  large  fungous  mass  growing  from  the  scro- 
tum. The  slow,  painless  course  of  this  lesion  suggested  its  syphilitic 
nature.  While  under  treatment  for  this  affection  the  patient  complained 
of  pain  in  the  rectum,  attended  by  bloody  and  diarrhoeal  discharges  ;  very 
soon  a  brownish-black  ill-smelling  mass  was  found  protruding  from  the 
anus,  which,  after  removal,  proved  to  be  composed  of  connective  and 
elastic  tissue.  On  digital  examination  a  swelling  the  size  of  a  walnut  was 
discovered  on  the  right  wall  of  the  rectum,  from  which  a  sanious  pus 
could  be  expressed.  Periosteal  nodes  were  also  present  at  this  time. 
Zeissl  quotes  Virchow  as  saying  that  there  is  nothing  absolutely  specific 
in  the  formation  of  the  infiltrations  of  syphilis,  but  that  their  nature  is 
determined  by  their  development,  history,  course,  degeneration,  etc.  He 
concludes  that  the  anal  tumor  was  a  syi)hilitic  new  growth,  and  tiiat  it 
was  of  exceptional  importance  on  account  of  its  occurrence  in  a  male 
patient.  Barduzzi,^  an  Italian,  has  also  published  a  brochure  on  the  sub- 
ject of  syphilitic  stricture  of  the  rectum,  which  he  thinks  may  be  caused 
first  by  simple  ulcers  or  the  chancroid,  second  by  the  lesions  of  secondary 
syphilis,  third  by  those  of  tertiary  syphilis,  and  fourth  by  cancer.     His 

'  Ddplay,  Progrfes  med.,  Paris,  nov.  30,  1876. 

*  Zeissl,  Vrtljschr.  Dermat.  u.  Syph.,  Wien,  H.  II,  1876. 

8  Bakduzzi,  Gioi-.  ital.  d.  mal.  veil.,  Milano,  No.  I,  1875. 


608  AFFECTIONS    OF    THE    ORGANS    OF    DIGESTION. 

paper  also  contains  a  good  description  of  the  symptomatology  and  some 
suggestive  points  in  the  diagnosis  of  cancerous  strictures. 

The  literature  of  this  subject  has  been  further  increased  by  the  publi- 
cation by  Zap[)ula'  of  a  case  of  rectal  stricture,  in  which  cure  was  effected 
by  the  internal  use  of  iodide  of  potassium.  The  patient,  a  man  36  years 
of  age,  had  gonorrhoea  and  an  ulcer  on  the  glans  fifteen  years  before. 
Mercurial  treatment  was  at  once  begun,  and  no  lesions  of  syphilis  subse- 
quently appeared.  Fifteen  years  later  he  began  to  suffer  from  pains  to  the 
right  of  the  anus  and  in  the  right  tuberosity  of  the  ischium.  Very  soon 
the  symptoms  of  rectal  stricture  became  well  marked,  and  so  extreme  was 
tlie  intestinal  obstruction  that  large  fecal  tumors  formed,  and  could  be 
felt  through  the  abdominal  walls.  Upon  examining  the  rectum  with  the 
finger,  smooth,  elastic  elevations  of  the  mucous  membrane  were  felt,  rather 
in  the  form  of  folds  than  of  condylomata  or  other  adventitious  deposits. 
Examination  with  the  speculum  showed  the  mucous  membrane  hypertro- 
phied,  uniformly  swollen,  and  slightly  mammillaied.  A  sound  could  be 
readily  introduced  to  a  depth  of  eleven  centimetres  (four  and  a  half  inches), 
but  there  met  an  impassable  obstruction.  On  a  second  examination  there 
was  found  at  a  depth  of  four  centimetres  (one  and  six-tenths  inch)  a  pain- 
less swelling  the  size  of  a  hazelnut,  globular,  smooth  and  elastic,  which 
was  situated  beneath  the  mucous  membrane,  and  appeared  not  to  adhere 
to  the  latter.  The  diagnosis  lay  between  syphilis  and  cancer.  Giving 
the  patient  the  benefit  of  the  doubt,  he  was  placed  upon  anti-syphilitic 
treatment,  consisting  of  large  doses  of  the  iodide  of  potassium.  In  the 
course  of  twelve  days  tlie  pain  disappeared,  the  tumor  diminished  in  size, 
natural  stools  took  place,  and  the  patient  was  at  last  completely  restored 
to  health. 

According  to  Fournier,  Guerin  also  obtained  good  results  from  the 
iodide  of  potassium  in  rectal  stricture. 

Treatment. — It  has  only  been  exceptionally,  as  in  Zappula's  caee 
above  given,  that  the  potassium  iodide  and  mercurials  have  had  any  effect 
in  relieving  stricture  of  the  rectum.  Their  success,  however,  in  these 
few  instances  should  lead  us  to  give  them  a  trial  in  all.  At  the  outset  of 
the  disease,  dilatation,  either  alone  or  combined  with  incisions,  may  effect 
a  cure  ;  at  a  later  stage,  they  are  in  most  cases  at  best  palliative,  and  a 
fatal  termination  can  only  be  delayed  for  a  time  by  the  use  of  sounds,  tlie 
administration  of  tonics,  and  general  hygienic  means. 

An  important  modification,  however,  of  the  treatment  of  these  stric- 
tures by  dilatation  has  been  successfully  employed  by  Dr.  McMasters^  of 
St.  Francis  Hospital,  xSew  York.  The  patient  was  a  man,  twenty-three 
years  of  age,  who  had  been  infected  two  years  previous.     Fifteen  months 

'  Zappula,  Ann.  univ.  di  med.,  Milano,  CCXIII,  1870  ;  also  Arch.  f.  Dermat.  u. 
Ijyph.  Prag.,  1871,  pp.  62  and  90. 

2  McMasters,  Treatment  of  syphilitic  stricture  of  the  rectum  by  means  of  pres- 
sure, and  the  local  application  of  mercurial  ointment.    N.  York  M.  J.,  Oct.  1876. 


THE    LIVER.  609 

after  the  primary  lesion  lie  complained  of  symptoms  of  rectal  stricture, 
which  were  not  treated,  and  which  gradually  increased  for  ten  months. 
When  he  came  under  treatment  his  stricture,  which  was  just  within  the 
sphincter,  scarcely  admitted  a  No.  12  bougie.  After  unsuccessful  treatment 
by  incisions  and  dilatation.  Dr.  McMasters  introduced  a  piece  of  wood 
covered  with  flannel,  saturated  with  mercurial  ointment,  and  so  shaped  as 
to  exactly  fit  the  stricture.  Having  been  retained  for  twenty-four  hours  by 
means  of  a  perineal  band,  it  was  withdrawn,  and,  after  the  application  of 
another  thickness  of  flannel,  anointed  as  before,  it  was  reinserted.  After 
daily  repetition  of  this  procedure  for  two  weeks,  the  stricture  was  large 
enough  to  admit  the  index-finger,  and,  at  the  end  of  five  weeks,  its  diam- 
eter was  nearly  one  inch,  which  was  subsequently  increased  to  one  inch 
and  three-eighths.  The  treatment,  being  continuous,  required  confinement 
of  the  patient.  For  the  first  twenty-four  hours  the  wooden  plug  caused 
slight  discomfort,  but  afterwards  no  inconvenience  was  experienced. 
Cure  was  hastened  by  the  internal  use  of  the  iodide  of  potassium. 

The  Liver. 

The  liver  is  attacked  by  syphilis  more  frequently  than  any  other  of  the 
abdominal  viscera.  In  the  secondary  stage  congestion  of  the  liver  some- 
times occurs,  usually  associated  with  a  cutaneous  eruption.  The  most 
marked  symptom  is  icterus^  which  is  of  short  duration  and  may  be  accom- 
panied by  gastric  disturbance  and  febrile  reaction.  There  is  a  sense  of 
weight  or  oppression  in  the  hepatic  I'egion,  but  seldom  any  pain,  except 
perhaps  on  pressure.  Percussion  may  show  ■slight  increase  in  the  volume 
of  the  organ.  Tliis  condition,  Avhich  was  first  described  by  Gubler  in 
1853,  is  probably  due  to  the  extension  of  a  catarrh  from  the  intestine  to 
the  bile-duct.  The  fact  that  it  usually  accompanies  a  specific  exanthem, 
simultaneously  with  which  it  often  disappears,  suggests  the  possibility  of 
an  analogous  condition  of  the  intestine.  It  rarely  persists  more  than  a 
week  or  two.  The  icterus  occurring  at  a  later  period  of  syphilis  may,  of 
course,  be  due  to  interference  with  the  transmission  of  the  bile  by  mere 
congestion  of  the  liver;  more  frequently  it  is  caused  by  compression  from 
a  gumma  or  a  cicatricial  band. 

The  affections  of  the  liver  observed  in  the  later  stages  of  syphilis  are 
much  more  serious  and  present  more  decided  symptoms.  Three  forms  of 
tertiary  syphilis  of  the  liver  are  usually  recognized: — 

1.  Chronic  Interstitial  Hkpatitis. 

2.  Gummata. 

3.  Amyloid  Degeneration. 

Chronic   Interstitial   Hepatitis. — Clironic   interstitial   hepatitis 

may  be  general  or  partial;  the  former  condition  is  rare,  and  cannot  be 

distinguislied  from  ordinary  cirrhosis.     In  the  localized  form  the  increase 

of  fibrous  tissue  is  especially  marked  in  the  capsule  of  Glisson  at  the 

39 


filO  AFFECTIONS    OF    THE    ORGANS    OF    DIGESTION. 

attachment  of  ligaments.  The  subsequent  contraction  of"  the  newly-formed 
tissue  causes  very  striking  lobulation  of  the  organ. 

Upon  post-mortem  examination  the  liver  is  found  to  be  united  to  the 
neighboring  organs  and  to  the  diaphragm  by  means  of  ligamentous  bands, 
whicli  are  so  firm  that  it  is  often  difhcult  to  remove  it  from  its  position. 
The  external  appearance  is  highly  characteristic.  Its  natural  contour  is 
often  lost,  so  that  its  different  portions  are  with  difficulty  recognized.  Its 
edges  are  uneven  and  fissured.  Its  surfaces  present  irregular  prominences 
or  lobes,  se[)arated  by  furrows  radiating  for  the  most  part  from  the  sus- 
pensory ligament,  and  dense,  grayish,  and  fibrous  at  the  bottom. 

On  making  a  section,  thickened  strise  or  septa  are  found  to  emanate 
from  the  fibrous  bands  upon  the  surface,  and  permeate  the  substance  of 
the  organ,  enclosing  interspaces  in  which  the  hepatic  tissue  is  of  a  deeper 
and  more  yellow  color  than  normal.  Under  the  microscope  the  hepatic 
cells  are  enlarged  and  fatty,  or  they  have  undergone  amyloid  degeneration, 
while  in  the  neighborhood  of  the  septa  they  are  commonly  atrophied. 

The  size  of  the  liver  may  be  moderately  increased  during  the  early 
vascular  stage,  but  it  is  commonly  diminislied  at  a  later  period,  and  in 
one  case  reported  by  Frerichs,  it  did  not  exceed  that  of  a  man's  fist. 

The  symptoms  of  this  affection  are  those  of  ordinary  cirrhosis,  consisting 
of  loss  of  appetite,  emaciation,  ascites,  etc. 

GuMMATA Gummata  are  commonly  found  imbedded  in  fibrous  tissue, 

and  are  usually  small  and  multiple.  They  are  seldom  larger  than  a 
walnut,  and  are  frequently  arranged  in  groups.  Their  outline  is  irregular 
and  their  consistency  firm.  jCorniP  describes  the  structure  of  a  gummy 
tumor  of  the  liver  as  follows:  it  consists  of  three  portions  ;  a  central  mass, 
homogeneous  or  composed  of  granular  matter,  imbedded  in  which  are 
small  round  cells.  These  cells  are  arranged  in  groups  which  are  separated 
by  delicate  filaments  of  connective  tissue.  Around  this  central  portion  is 
an  intermediate  zone  composed  of  fibrous  tissue,  which,  when  recent,  in- 
closes numerous  round  cells;  when  older,  the  cells  are  scanty  and  fusi- 
form. The  third  or  external  zone  consists  of  condensed  hepatic  tissue, 
which  is  filled  with  cells  and  is  penetrated  by  fibres  of  connective  tissue 
from  the  middle  zone.  In  the  central  portion  of  the  gumma  the  vessels 
are  very  small  or  are  completely  obliterated.  The  vessels  of  the  periphery 
are  large  and  their  walls  are  thickened.  Scattered  among  the  new  cells 
are  small,  round,  highly  refractive  bodies,  not  acted  upon  by  carmine,  but 
deeply  colored  by  purpurine,  which  Malassez^  considers  peculiar  to  syphilis. 
In  rare  cases  the  gummatous  deposit  softens  and  is  absorbed;  still  more 
rarely  it  undergoes  calcific  degeneration  ;  commonly  the  tumor  contracts, 
and  is  transformed  into  fibrous  tissue,  in  which  no  traces  of  its  original 
layers  can  be  found. 

These  gummatous  tumors  may  be  distinguished  from  tubercular  nodules 

'  Lemons  sur  la  syphilis,  Paris,  1879. 
2  JuLLiEN,  Mai.  ven^rleimes,  Paris,  1879. 


AMYLOID    DEGENERATION    OF    THE    LIVER.  611 

by  the  fact  that  the  latter  are  much  smaller  and  more  numerous.  The 
centre  of  a  tubercle,  moreover,  is  soft,  and  perhaps  puriform  ;  its  fibrous 
periphery  is  narrower  and  less  dense  than  that  of  a  gumma.  Gummy 
tumors  can  hardly  be  confounded  with  cancerous  or  sarcomatous  tumors. 

The  symptoms  of  gummata  of  the  liver  are  often  obscure,  and  the  diag- 
nosis must  be  confirmed  by  coincident  lesions.  The  organ  may  be  in- 
creased in  volume,  and  nodules  may  be  detected  upon  its  surface.  Pain 
may  be  entirely  absent,  except  on  pressure,  or  it  may  be  very  acute :  it 
does  not  radiate  towards  the  shoulder  as  in  other  hepatic  affections.  Res- 
piration may  be  painful  in  consequence  of  adhesions.  Unless  the  tumors 
are  extremely  numerous,  there  is  no  interference  with  the  functions  of  the 
organ.  In  severe  cases  there  may  be  icterus  and  gastro-intestinal  disturb- 
ances. The  stools  may  be  clay-colored  or  bloody.  Blood  may  also  be 
expectorated,  and  epistaxis  may  occur.  The  spleen  and  the  abdominal 
ganglia  are  often  deci<ledly  hypertrophied.  The  urine  may  contain  albu- 
men. There  is  sometimes  a  tendency  to  anasarca,  in  consequence  of  some 
unknown  changes  in  the  blood.  The  skin  is  dry  and  bronzed.  The  tem- 
perature of  the  body  is  somewhat  diminished. 

Gummy  tumors  of  the  liver  may  be  mistaken  for  cancer  or  for  hydatid 
cysts.  Cancer  occurs  at  an  advanced  age  and  invades  both  lobes ;  it  is 
usually  attended  by  marked  pain  and  by  cachexia ;  icterus  is  generally 
present ;  the  duration  of  cancer  is  greater  than  that  of  gummata.  In 
hydatid  cysts  fluctuation  and  frequently  the  pathognomonic  vibratory  thrill 
may  be  detected.  The  tumors  often  extend  towards  the  epigastrium  and 
simulate  gastric  disease,  although  digestive  troubles  are  rare.  Disturbance 
of  respiration  and  ascites  are  also  infrequent. 

The  prognosis  of  gummata  of  the  liver  is  less  serious  than  that  of  inter- 
stitial hepatitis ;  when  death  occurs  it  is  usually  due  to  some  intercurrent 
affection. 

Amyloid  Degeneration Amyloid  degeneration  of  the  liver  is  not 

peculiar  to  syphilis.  It  is  often  accompanied  by  fatty  degeneration  or  in- 
terstitial hepatitis.  The  morbid  changes  involve  the  hepatic  cells,  begin- 
ning, according  to  Green,  in  the  small  nutrient  bloodvessels.  The  hepatic 
cells  are  found  to  be  enlarged,  with  irregular  outlines,  many  of  them  having 
coalesced ;  the  nuclei  of  some  have  disappeared.  This  amyloid  change 
differs  in  its  seat  from  the  fatty  and  the  pigmentary  degenerations;  in  the 
fatty  the  deposit  takes  place  in  the  external  portions  of  the  lobule;  pig- 
mentation occurs  chiefly  at  the  centre;  while  amyloid  degeneration  is  most 
marked  in  the  intermediate  portion.  Sometimes  these  three  processes  occur 
simultaneously. 

The  amyloid  liver  is  heavier  and  much  enlarged,  sometimes  almost 
filling  the  abdominal  cavity.  There  is  no  lobulation  of  the  organ,  which 
may  retain  its  form  although  greatly  enlarged.  If  fatty  deposit  also  occurs, 
however,  the  margins  are  rounded  and  the  natural  furrows  are  obliterated. 
The  consistence  of  the  liver  is  firm,  and  its  cut  surface  is  dry,  bloodless, 


612  AFFECTIONS    OF    THE    ORGANS    OF    DIGESTION. 

and  lias  a  translucent,  waxy  appearance.  The  change  of  color  to  violet 
or  blue,  on  the  application  of  iodine  and  sulphuric  acid,  is  characteristic. 

The  symptoms  resemble  those  of  cirrhosis.  The  portal  circulation  is 
seldom  obstructed,  hence  ascites  is  rare.  The  hepatic  cells  being  destroyed 
the  functions  of  the  liver  are  abolished.  Gastro-intestinal  disturbance 
and  albuminuria  are  often  observed.  The  spleen  may  be  enlarged  at  the 
same  time.     Recovery  is  very  rare. 

The  treatment  of  these  lesions  of  the  liver  is  that  appropriate  to  the  late 
stages  of  syphilis. 

According  to  Lacombe,^  Hayem  has  found  in  livers  affected  by  syphilis 
a  perilymphangitis  comparable  to  the  nodular  form  of  lymphangitis  some- 
times seen  in  the  skin.  In  such  a  case,  we  find  in  the  fibrous  bands  of 
newly  formed  tissue,  numerous  lymphatic  vessels  which  are  much  dilated 
and  surrounded  as  if  by  a  muff  of  connective  tissue.  When  the  lymphatic 
is  cut  perpendicularly  to  its  axis,  it  appears  like  a  small,  round,  fibrous 
nodule,  in  the  centre  of  which  is  an  opening.  When,  however,  it  is  cut 
more  or  less  parallel  to  its  axis,  we  find  in  a  thickened  fibrous  tract  a 
simple  slit,  often  enlarged  at  one  of  its  extremities,  and  of  which  the  lumen 
is  sometimes  empty  and  sometimes  filled  with  a  granular  and  cellular 
exudation.  This  perilymphatic  inflammation  is  found  in  the  thickness  of 
the  capsule  of  Glisson,  and  is  observed  in  many  cases.  The  bloodvessels 
are  also  sometimes  compressed  and  obliterated  by  the  tissue  which  sur- 
rounds them. 

The  Spleen. 

In  some  rather  rare  instances  enlargement  of  the  spleen  occurs  early  in 
the  course  of  syphilis.  The  swelling  is  quite  rapid,  and  in  some  cases  is 
evident  on  palpation  ;  in  others  it  can  be  determined  only  by  percussion. 
The  patient  usually  feels  no  pain  nor  discomfort,  but  when  the  organ  is 
enlarged  to  four  or  five  times  its  normal  size  a  sensation  of  dragging  weight 
is  complained  of.  The  average  degree  of  enlargement  is  twice  the  normal 
size. 

The  course  of  this  affection  depends  largely  on  treatment,  under  which 
the  swelling  usually  subsides  in  from  three  to  four  weeks ;  in  exceptional 
cases  it  persists  for  several  months.  A  relapse  may  occur  within  a  few 
weeks  or  months,  and  sometimes  the  swelling  increases  after  having  been 
stationary  for  a  time. 

We  have  met  with  six  marked  cases  of  this  affection,  four  in  males  and 
two  in  females ;  in  each  case  there  was  mild  cachexia,  and  in  two  dis- 
turbance of  the  appetite.  We  have  never  been  able  to  discover  this  en- 
largement until  the  secondary  period  of  syphilis ;  yet  WeiP  and  Wever^ 

'  Etude  sur  les  accidents  h^imtiques  de  la  syi>h.  chez  Tadulte.     Paris,  1874. 

"  Weil  :  Ueber  das  Vorkomtnen  des  Milztumors  bei  frisclier  Syphilis.  Centralbl. 
f.  d.  med.  Wissensch.,  Berl.  No.  12,  1874.  Also,  Ueber  das  Vorkommen  des 
Milztumors,  etc.     Deutsches  Arch.  f.  klin.  Med.,  Leipz.     Bd,  13,  H.  3,  1874. 

3  Wevek  :  Ueber  das  Vorkommen  des  Milztumors,  etc.  Deutsches  Arch.  f.  klin. 
Med.,  Leipz.     H.  4  u.  5,  1876. 


GUMMATA    OP    THE    SPLEEN.  613 

state,  in  their  monographs,  that  they  have  found  it  during  the  secondary 
period  of  incubation.  Of  three  cases  observed  by  the  latter,  in  one  it  was 
found  between  the  eighth  and  twelfth  weeks  of  infection  ;  in  another  be- 
tween the  fifth  and  tenth  weeks  after  the  initial  lesion  ;  and  in  the  third 
during  tlie  first  two  weeks  of  the  secondary  stage.  In  three  of  our  cases 
it  was  found  within  a  month  after  general  invasion,  and  in  the  remainder 
between  three  and  eight  months.  Probably  it  may  occur  at  any  time 
during  the  secondary  period.  Jullien  attributes  to  this  condition  of  the 
spleen  many  of  the  symptoms  of  gastric  derangement  as  well  as  certain 
blood  changes  occurring  in  syphilitic  patients. 

We  are  ignorant  of  the  minute  changes  in  the  splenic  enlargement  of 
syphilis,  but  probably  they  consist  of  increase  of  the  cell  elements  of  the 
pulp  with  hyperemia,  as  suggested  by  Weil. 

In  all  cases  of  enlarged  spleen  thought  to  have  a  syphilitic  origin,  other 
causes  must  be  eliminated. 

GuMMATA  OF  THE  Spleen Gummata  vary  in  size  from  that  of  a 

millet-seed  to  that  of  a  walnut,  and  may  be  few  in  number  or  very  numer- 
ous. Their  number  is  usually  greater  when  their  size  is  small.  In  some 
cases  the  spleen  itself  is  enlarged.  The  tumors  are  usually  found  near  the 
trabeculaj  and  deeply  seated,  or  at  the  periphery  of  the  organ  ;  in  the 
latter  case  the  capsule  is  thickened.  Recent  tumors  have  a  reddish-gray 
color,  and  are  more  dense  and  tough  than  the  normal  spleen  tissue ;  when 
old  they  are  dry  and  of  a  yellowish-gray  color.  When  young  they  are 
less  clearly  defined  than  at  a  later  period,  when  they  may  become  distinctly 
encapsulated.  The  vessels  and  the  structure  of  the  organ  in  the  neighbor- 
hood of  the  tumors  are  more  or  less  destroyed.  Cicatricial  contraction, 
especially  in  the  capsule,  subsequently  occurs.  The  spleen  has  several 
times  been  found  adherent  to  the  diaphragm  in  consequence  of  peritonitis 
from  irritation  by  gummy  tum.ors. 

We  know  little  of  the  symptomatology  of  this  affection.  Enlargement 
of  the  spleen  is  sometimes  demonstrable,  and  in  some  cases,  when  the 
tumors  are  superficial,  inflammation  of  the  capsule  and  localized  peritonitis 
occur. 

In  the  cases  hitherto  observed  the  lesion  has  generally  been  accompanied 
by  similar  affections  of  other  viscera,  and  the  patients  have  suffered  from 
cachexia  or  marasmus. 

According  to  Biiumler,  Beer  thinks  that,  besides  gummata,  syphilis 
causes  in  the  spleen  a  diffuse  cellular  infiltration  of  the  arterial  sheaths, 
and  certain  characteristic  deposits,  which  are  as  follows  :  "  They  are  paler 
than  the  normal  tissue,  from  which  they  do  not  project  at  all,  but  merge 
diffusely  into  the  surrounding  spleen  tissue;  contain  but  little  blood  and 
few  cells,  and  in  the  centre  consist  of  a  finely  granular  material  in  which 
a  few  cells  and  nuclei  are  embedded." 


614  affections  of  the  organs  of  digestion. 

Pancreas. 

Upon  this  subject  Lancereaux  remarks:  "Cases  showing  syphilitic 
changes  in  the  pancreas  are  extremely  rare.  In  a  patient  who  died  under 
the  care  of  Prof.  Rostan  fourteen  years  after  having  contracted  a  chancre, 
there  was  found,  besides  multiple  gummata  of  the  muscles,  a  gummy  tumor 
of  the  mammary  region,  and  two  others  in  the  pancreas.^  All  these  tumors, 
subjected  to  microscopic  examination  by  Verneuil  and  Robin,  appeared  to 
be  composed  of  similar  elements.  I,  myself,  in  several  cases  of  visceral 
syphilis,  have  found  this  organ  firm,  indurated,  and  sclerosed,  so  that  we 
cannot  deny  that  the  pancreas,  like  most  of  the  viscera,  is  subject  to  the 
diflPuse  and  circumscribed  lesions  of  syphilis." 

'  Bull.  Soc.  aiiat.  de  Paris,  1855,  p.  26. 


THE    NOSE.  615 


CHAPTER    XVII. 
AFFECTIONS    OF   THE    ORGANS   OF   RESPIRATION. 

The  Nose. 

The  pituitary  membrane  may  be  the  seat  of  erythema,  superficial  ulcer- 
ations, and  mucous  patches,  which  giv^e  rise  to  symptoms  resembling  those 
of  an  ordinary  catarrli.  Sometimes  an  ulcer  may  be  seen  just  within  the 
nasal  orifice,  surrounded  by  swollen  mucous  membrane,  and  rendering  the 
alai  nasi  tender  upon  pressure.  Plugs  of  inspissated  mucus,  mixed  with 
blood  and  pus,  which  obstruct  the  passages,  are  from  time  to  time  dis- 
charged. The  nasal  secretion  is  more  abundant  and  more  purulent  when 
ulcerations  or  mucous  patches  exist.  In  the  absence  of  other  lesions  of 
s}i)hilis,  upon  the  skin  or  elsewhere,  the  character  of  the  nasal  affections 
may  be  suspected  only  because  of  their  persistence  and  of  their  rapid  dis- 
appearance under  specific  treatment. 

In  the  more  advanced  stages  of  syphilis,  deeper  ulcers  appear,  which 
originate  in  gummatous  infiltration  of  the  submucous  tissue  and  gradually 
involve  the  cartilaginous  and  osseous  textures;  or  the  latter  structures 
may  be  the  first  attacked,  and  the  mucous  membrane  become  implicated 
secondarily.  On  account  of  the  serious  deformity  resulting  from  destruc- 
tion of  the  framework  of  the  nose,  the  importance  of  recognizing  these 
lesions  at  an  early  period  is  very  great.  Their  progress  is  usually  very 
slow  and  insidious,  so  much  so  that  necrosis  may  occur  before  the  patient 
is  conscious  of  any  serious  trouble.  The  ulcerative  process  may  [)erforate 
the  septum  or  the  floor  of  the  nasal  cavity,  or  it  may  extend  into  the 
pharynx.  Again,  it  may  find  its  way  along  the  Eustachian  tube  and  even 
penetrate  the  cranial  cavity,  involving  the  meninges;  more  commonly, 
however,  the  membrana  tympani  becomes  ruptured  and  a  purulent  dis- 
charge takes  place  tlirough  the  external  auditory  canal.  Deafness  may 
ensue  from  obliteration  of  the  Eustachian  tube  by  a  cicatrix.  The  disease 
has  been  known  to  pass  up  the  lachrymal  canal,  involving  the  lachrymal 
bone  and  even  the  eye. 

Respiration  through  the  nose  may  be  interfered  with  by  hy[)ertropliy  of 
the  mucous  membrane,  by  the  formation  of  adhesions  between  ulcerating 
surfaces  in  process  of  repair,  or  by  the  contraction  of  cicatrices.  The 
voice  becomes  nasal ;  the  sense  of  smell  may  be  impaired  or  lost,  even 
whea  the  terminal  filaments  of  the  olfactory  nerve  are  not  involved;  the 
discharge,  in  cases  of  necrosis,  is  extremely  fetid  and  may  contain  frag- 
ments of  bone.     When  necrosis  of  tlie  nasal  bones  occurs,  the  bridge  of 


616  AFFECTIONS    OP    THE    ORGANS    OF    RESPIRATION. 

the  nose  becomes  depressed  and  its  tip  elevated ;  when  the  cartilages  are 
destroyed,  the  tip  of  the  nose  is  depressed  and  flattened.  Tlie  portions  of 
bone  spared  by  the  destructive  process  become  thickened  and  eburnated, 
and  are  often  separated  superiorly  so  as  to  form  a  longitudinal  furiow 
running  along  the  dorsum  of  the  nose.  According  to  Virchow,^  this  ten- 
dency to  eburnation  and  thickening  of  the  osseous  tissue  is  not  confined 
to  the  part  first  affected,  but  may  extend  to  the  bones  composing  the  base 
of  the  skull. 

Treatment  of  Lesions  of  the  Nose. 

The  earlier  syphilitic  affections  of  the  nasal  passages  readily  yield  to 
the  internal  administration  of  mercurials,  and  rarely  require  topical  appli- 
cations. In  tertiary  affections,  iodide  of  potassium,  preparations  of  iron, 
the  mineral  acids,  cod-liver  oil,  and  other  tonics  must  frequently  be  em- 
ployed either,  alternately  or  in  combination,  and  for  a  long  period,  in 
order  to  afford  permanent  relief  to  the  disgusting  and  distressing  symp- 
toms. As  a  general  rule,  however,  the  iodide  of  potassium  in  large 
doses,  together  with  the  cautious  use  of  mercurial  inunction,  will  suffice 
to  effect  a  cure.  The  most  efficacious  local  treatment  consists  in  mer- 
curial fumigations,  which  may  be  administered  by  means  of  the  ordi- 
nary mercurial  vapor  bath,  provided  the  general  health  of  the  patient  be 
not  too  much  reduced ;  but  a  more  convenient  method  is  to  evaporate  a 
sufficient  quantity  of  calomel,  the  bisulphuret  or  binoxide  of  mercury  from 
a  metallic  plate  heated  over  a  spirit  lamp,  directing  the  fumes  into  the 
nostrils  by  means  of  a  tunnel  of  paper  or  other  convenient  material.  Blood- 
Avarm  injections  of  salt  and  water  (5J  ad  Oj),  diluted  chlorinated  soda 
(one  part  to  twelve  or  twenty  of  water),  and  weak  solutions  of  nitrate  of 
silver  or  chloride  of  zinc,  by  means  of  a  syringe,  or  with  Thudichum's 
apparatus,  will  also  be  of  much  service.  1  most  frequently  employ  a  strong 
solution  of  chlorate  of  potash.  It  must  be  recollected  that  the  discharge' 
will  still  continue  as  long  as  there  are  any  necrosed  portions  of  bone  or 
cartilage  to  come  away.  Patients  and  even  physicians  are  too  apt  to 
despair  of  the  success  of  treatment  in  consequence  of  forgetting  this  fact. 

Before  making  any  of  the  above  applications,  the  nasal  passages  should 
be  thoroughly  cleaned  by  the  use  of  Thudichum's  apparatus,  or,  better 
still,  by  a  douche  directed  from  behind  forwards. 

The  Larynx. 

Before  the  invention  of  the  laryngoscope,  knowledge  of  the  syphilitic 
affections  of  the  larynx  was  derived  chiefly  from  the  study  of  post-mortem 
appearances.  Reasoning  by  analogy,  it  was  the  custom  to  infer  the  exist- 
ence of  laryngeal  lesions  corresponding  with  those  manifested  on  parts 

1  Ueber  dcr  Natur  der  constitutionellen  Syphilis. 


THE    LARYNX.  617 

within  the  reach  of  visual  examination.^  Thus  all  syphilitic  diseases  of 
the  larynx  were  believed  to  be  propagated  from  those  occurring  primarily 
in  the  pharynx,  and  they  were  thought  to  follow  the  same  laws,  regarding 
their  time  and  mode  of  development,  as  the  dermal  lesions  of  syphilis- 
Modern  research  has  shown  these  theories  to  be  erroneous.  AVe  know  that 
the  larynx  maybe  the  seat  of  syphilitic  lesions  independently  of  manifesta- 
tions in  the  pharynx,  although  these  regions  are  usually  involved  at  the  same 
time.  Moreover,  the  laryngeal  lesions  are  so  erratic  as  regards  the  time 
of  their  appearance,  and  so  modified  by  their  situation  that  their  arbitrary 
division  into  secondary  and  tertiary  is  impracticable.  It  is  desirable, 
however,  in  order  to  obtain  a  clear  idea  of  these  affections,  to  adopt  some 
system  of  classification.  Provided  it  be  borne  in  mind  that  they  refer  to 
the  depth  and  extent  of  the  lesions  rather  than  to  the  time  of  their  occur- 
rence, it  may  be  as  well  to  retain  the  terms  secondary  and  tertiary. 
Among  secondary  or  superjicial  lesions,  therefore,  may  be  included: 

1.  Erythema. 

2.  Superjicial  ulcerations. 

3.  Mucous  patches. 

■1.    Chronic  injiammation  tcith  hypertrophy  of  the  mucous  mem- 
hrane.      Vegetations. 

Tertiary  or  deep  lesions  comprise  : 

1.  Deep  ulcerations. 

2.  Gummy  tumors. 

3.  Perichondritis  and  Chondritis. 

4.  Caries  and  Necrosis. 

With  regard  to  laryngeal  syphilis  in  general  it  seems  to  be  true  that  the 
more  remote  a  lesion  is  from  the  entrance  to  the  larynx  the  more  serious 
will  be  its  consequences,  and  that  the  subjective  symptoms  of  a  lesion  are 
by  no  means  commensurate  with  its  gravity.  For  instance,  a  superficial 
ulcer  may  be  complicated  by  an  acute  oedema  so  general  and  so  excessive 
as  to  threaten  life ;  on  the  other  hand,  a  destructive  process  may  have  gone 
on  to  a  considerable  degree  while  the  patient  is  in  ignorance  of  his  con- 
dition. The  invasion  of  the  larynx  by  syphilis  is  usually  very  insidious, 
and  the  subsequent  course  of  the  lesions  is  chronic  and  devoid  of  pain. 
Gerhardt  and  Roth''  express  the  opinion  that  the  parts  of  the  vocal  organ- 
ism most  often  in  contact  during  the  performance  of  its  function  are  more 
frequently  attacked  by  syphilis.  Hence  the  vocal  cords  and  the  arytenoids 
are  the  most  susceptible  regions. 

There  are  certain  symptoms,  some  of  them  common  to  many  of  the 
lesions  of  laryngeal  syphilis,  which  deserve  special  attention.  Spontaneous 
pain  is  very  rare.  It  is  considered  an  indication  of  the  invasion  of  fibrous 
or  cartilaginous  tissues.    Pain  in  the  ear  and,  when  the  lesion  is  unilateral, 

•  Dance  ;  Eruptions  syph.  du  larynx.     Th^se  do  Paris,  1864. 
2  Uebor  sypli.  Krankheiten  des  Kehlkopfes,  Arch.   f.  path.  Anat.,  etc.,  Berl. 
H.  xxi,  1861. 


618  AFFECTIONS    OF    THE    ORGANS    OF    RESPIRATION. 

in  the  ear  corresponding  to  the  affected  side,  is  spoken  of  by  Jullien*  as  a 
symptom  in  many  cases,  although  not  peculiar  to  syphilitic  disease  of  the 
larynx. 

Cough  is  also  an  extremely  rare  symptom,  and  exj)ectoration,  if  present, 
is  scanty,  mucous  or  muco-purulent.  The  sputa  may  be  tinged  with  blood 
from  an  ulcerative  lesion  or  from  ruptured  capillaries.  In  cases  of  caries 
or  necrosis  they  may  contain  fragments  of  cartilage  or  bone.  In  the  latter 
condition  also  the  breatli  is  likely  to  have  a  fetid  odor. 

Alteration  in  the  volume  and  quality  of  the  voice  may  be  very  slight 
even  in  severe  lesions.  Frequently  the  voice  becomes  hoarse  or  assumes 
a  character  called  by  the  French  "  crapuleuse."  Sometimes  it  is  reduced 
to  an  almost  inaudible  whisper. 

Dysphagia  is  quite  infrequent  except  in  very  advanced  stages  of  disease, 
or  when  the  epiglottis  is  attacked. 

Dyspnoea  may  supervene  in  cotisequence  of  stenosis  due  to  various 
causes,  chief  of  which  are  oedema,  growths  which  invade  tlie  air-passages, 
or  occlude  tliem  by  pressure  from  without,  and  cicatricial  contractions. 
Probably  spasm  may  be  an  occasional  and  temporary  cause  of  dyspnoea. 
Oedema  may  occur  with  any  lesion  of  syphilis.  The  sub-mucous  effusion 
may  take  place  rapidly,  in  which  case  the  danger  to  life  is  imminent,  or  it 
may  be  gradual.  In  the  latter  case  the  patient  may  accommodate  himself 
to  a  very  considerable  diminution  in  the  calibre  of  the  larynx.  The  dis- 
appearance of  an  acute  ojdema  is  usually  proportionately  rapid,  while  a 
slowly-formed  effusion  may  persist  for  a  long  time.  Among  new  growths 
which  may  cause  stenosis  of  the  larynx,  are  to  be  included  vegetations, 
hypertrophy  of  the  mucous  membrane  following  chronic  inflammation, 
gummy  tumors  and  exostoses.  The  most  intractable  cases  of  stenosis  are 
those  due  to  gradual  contraction  of  cicatrices.  This  unfortunate  result 
usually  follows  only  the  deep  ulcerations  of  the  later  stages  of  syphilis. 
Superficial  ulceration  may  involve  quite  extensive  sui-faces,  producing 
complete  aphonia  and  other  pronounced  subjective  symptoms,  yet  a  cure 
may  be  obtained  with  entire  restoration  of  the  functions  of  the  larynx.  It 
is  in  these  cases  of  stenosis  from  cicatricial  contraction  that  the  operation 
of  tracheotomy  is  sometimes  necessitated.  The  experience  of  Krishaber,'' 
however,  authorizes  confident  delay  of  surgical  means  of  relief,  even  in  the 
presence  of  alarming  dyspnoea  from  other  causes,  the  energetic  use  of  spe- 
cific remedies,  especially  by  the  hypodermic  method,  having  been  promptly 
efficacious  in  many  instances. 

The  larynx  may  also  be  occluded  by  the  formation  of  f\\lse  membrane 
between  the  vocal  cords.  This  is  rather  a  rare  cause  of  stenosis.  Ellsberg,' 
in  an  article  published  in  1874,  stated  that  in  about  270  cases  of  laryngeal 
syphilis  he  had  met  with   this  condition  six  times.     It  may  result  fl'om 

'  Mai.  vSnerieimos,  p.  835. 

2  Contribution  a  I'etude  des  troubles  resp.  dans  les  laryiigopathies  sypli.  Gaz. 
liebd.  1878,  Nos.  45^7. 

^  Syphilitic  membranoid  occlusion  of  the  rima  glottidis.  Am.  .J.  Syph.  and 
Derm.,  N.  Y.,  Jan.  1874. 


THE    LARYNX.  619 

superficial  ulceration  and,  on  the  contrary,  has  been  observed  in  conjunc- 
tion with  destruction  of  the  cartilages  and  other  late  lesions.  The  process 
appears  to  begin  usually  at  the  anterior  commissure,  leaving  a  passage  for 
the  air  posteriorly.  It  may  take  place  in  a  reverse  direction,  or  an  aper- 
ture may  be  left  in  the  middle  of  the  rima  glottidis,  or  along  the  edge  of 
the  vocal  cord.  This  condition  is  also  described  by  Sommerbrodt,^  who, 
with  Elsberg,  recommends  the  use  of  the  galvano-cautery  in  relieving  the 
dyspnoea,  and  adds  that  complete  restoration  of  the  voice  must  not  be  ex- 
pected. The  fact  that  in  many  cases  of  stenosis  the  obstacle  to  inspiration 
is  greater  than  to  expiration  lias  been  noticed  by  several  observers. 

Let  us  now  consider  the  special  lesions  which  may  occur  in  the  larjnx 
in  the  course  of  syphilis. 

Erythema Erythema  of  the  larynx,  unless  it  be  very  acute  and  at- 
tended by  oedema,  may  be  so  slight  as  to  attract  no  attention,  the  only 
symptoms  being  slight  huskiness  of  the  voice  and  moderate  catarrh.  No 
doubt  it  occurs  during  early  skin  eruptions,  and  it  is  frequently  developed 
at  more  advanced  stages,  either  independently  or  in  connection  with  deep 
laryngeal  lesions.  There  may  be  nothing  in  the  appearance  of  the  affec- 
tion to  distinguish  it  from  a  simple  catarrh.  It  occurs  either  in  patches, 
which  give  the  mucous  membrane  a  mottled  appearance,  or  it  may  be  limited 
to  certain  regions,  or  it  may  be  diffuse,  the  lining  of  the  larynx  having  a 
uniform  dusky-red  hue.  There  may  be  superficial  erosions  of  the  mucous 
membrane.  The  vascularity  of  the  affected  parts  is  much  increased, 
the  bloodvessels  often  presenting  the  appearance  referred  to  by  Krishaber 
and  Mauriac^as  "  arborisation."  When  the  epiglottis  particiiiates  in  the 
affection  and  in  the  concomitant  oedema,  it  may  be  much  tumefied  and 
assumes  a  bilobed  shape. 

Superficial  Ulceratioxs The  superficial  ulcerations  observed  in 

laryngeal  syphilis  involve  only  the  mucous  membrane  and,  according  to 
Baumler,^  usually  begin  in  mucous  follicles  at  the  posterior  commissure. 
They  may  affect  phonation  to  some  extent,  but  are  generally  very  sluggish, 
persisting  with  sliglit  change  for  an  indefinite  period.  Their  margins  are 
well-defined,  quite  regular,  and  very  slightly  elevated  above  the  surround- 
ing level.  The. surface  of  the  ulcers  is  usually  concealed  by  a  layer  of 
tenacious  secretion.  Frequently  general  erythema  of  the  mucous  mem- 
brane coexists..  These  early  ulcerations,  wliose  appearance  is  quite  differ- 
ent from  that  of  ulcers  occurring  at  a  later  period,  may  be  confounded  with 
incipient  tubercular  ulcers.  They  are  not  so  likely  as  are  the  late  ulcera- 
tions to  be  mistaken  for  cancerous  disease.  The  following  points  of  dis- 
tinction may  be  found  of  service.  The  ulcers  of  phthisis  begin  in  the 
ventricular  bands  and  are  usually  i)aler  than  tliose  of  syphilis.     They  are 

•  Bexl.  klin.  Wchnschr.  Apr.  1,  1878. 

2  Des  laryngopathios  syph.  pendant  les  premidres  ishases  du  la  sypliilis.  Paris, 
1870. 

3  Ziemssen's  Encycl.  vol.  iii,  p.  20G. 


620  AFFECTIONS    OF    THE    ORGANS    OF    RESPIRATION. 

bathed  in  a  copious,  muco-purulent  secretion.  There  is  decided  swelling 
and  oedema  of  the  arytenoids,  while  the  mucous  membrane  elsewhere  is 
anamiic.  The  course  of  phthisical  ulcers  is  more  rapid  and  painful,  and 
pulmonary  sym[)toms  coexist  or  are  soon  manifested.  Whistler^  observes 
that  in  syphilis  the  voice  is  rough  and  rasping,  while  in  phthisis  it  is  whis- 
pering and  moist,  suggesting  the  presence  of  excessive  secretion.  The 
absence  of  ulceration  in  the  mouth,  the  blanched  appearance  of  the  palate 
and  fauces,  Avhile  the  pharynx  may  be  congested,  are  indicative  of  the 
tubercular  character  of  laryngeal  ulceration.  Symmetry  in  the  position 
and  outline  of  syphilitic  ulcers  is  considered  characteristic  by  some  autho- 
rities. 

Mucous  Patches Great  diversity  of  opinion  has  prevailed,  even  since 

a  method  of  inspecting  the  larynx  during  life  has  been  provided,  regarding 
the  frequency  of  mucous  patches.  Pierre  Terras'^  considers  them  very  rare, 
having  found  them  in  only  one  instance  among  nearly  one  hundred  cases  of 
syphilis.  Krishaberand  Mauriac,  on  the  contiary,  found  ten  casesof  '■'■plaques 
nmqueiises"  in  fourteen  of  laryngeal  syphilis,  the  former  observer  discover- 
ing them  only  on  the  vocal  cords.  Whistler  states  that  he  has  met  with 
twenty-four  cases  of  this  lesion  among  eighty-eight  of  syphilis  in  its 
secondary  stage.  In  his  experience  the  time  of  its  occurrence  varied  from 
one  and  a  half  to  twelve  months  after  primary  infection.  In  all  cases 
mucous  patches  of  the  mouth  or  genitals  coexisted  ;  in  seven  cases  papular 
or  papulo-squamous  eruptions  were  found,  in  one  case  associated  with  a 
roseola.  In  one  case,  six  weeks  after  infection,  the  indurated  cicatrix  of 
a  chancre  was  still  present.  Enlarged  glands  and  alopecia  occurred  in 
many  instances.  In  ten  cases  the  epiglottis  was  the  seat  of  the  lesion  and 
in  ten  the  vocal  cords  ;  in  four  cases  the  arytenoids,  in  two  the  inter-ary- 
tenoid  fold,  in  two  the  ventricular  band,  and  in  one  the  glosso-epiglottic 
fold.  When  seated  on  parts  ex})Osed  to  irritation,  either  in  respiration  ot 
in  phonation,  mucous  patches  of  the  larynx  are  prominent  with  ragged 
margins,  forming  what  are  known  as  condylomata ;  in  other  regions  they 
are  flatter  and  the  ulceration  is  more  sharply  cut.  Their  surface  is  covered 
by  a  scanty,  viscid  secretion.  The  removal  of  this  film  exposes  a  red, 
excoriated  surface  in  striking  contrast  with  the  paler  hue  of  the  surround- 
ing mucous  membrane.  Sometimes  the  centre  of  a  patch  is  slightly  de- 
pressed, its  borders  remaining  prominent.  Besides  the  ulcerated  form  of 
mucous  patch  we  also  meet  with  the  opaline  patch,  according  to  Whistler, 
mon;  often  on  the  epiglottis  and  on  the  arytenoids.  In  these  lesions  the 
epithelium  is  thickened  and  still  adherent,  the  deeper  tissues  being  infil- 
trated with  new  cells.  Tlie  opalescent  appearance  is  attributed  by  Cor- 
niP  to  minute  collections  of  pus  amidst  the  epithelial  cells. 

'  The  early  manifestations  of  syphilis  in  tlie  larynx.     Med.  Times  and  Gaz., 
Lond.,  1878,  Nos.  1473-74-75-80-84. 
2  De  la  laryngite  syph.     Paris,  1872. 
^  Progres  med.,  Par.,  Aug.  10,  1878. 


THE    LARYNX.  621 

Chronic  Inflammation Chronic  inflammation  of  the  larynx  is  an 

intermediate  lesion  ;  it  may  follow  an  early  catarrh,  or  may  not  appear 
until  three  or  four  years  after  infection.  The  color  of  the  mucous  mem- 
brane is  decidedly  darker  than  in  the  early  erythemas,  although  Whistler 
affirms  that  it  never  deserves  the  name  "  coppery,"  which  has  been  ap- 
plied to  it  by  some  authors.  The  affection  is  very  persistent  and  com- 
monly leads  to  thickening  or  hypertrophy  of  the  mucous  membrane,  which, 
according  to  Krishaber  is  the  only  one  of  the  early  lesions  which  does  not 
disappear  spontaneously.  This  thickening  is  quite  different  from  the  oede- 
ma occurring  with  an  erythema,  in  which  the  mucous  membrane  has  a 
puffy  appearance.  The  thickening  of  the  cords  may  be  so  great  as  to 
require  operative  interference  for  the  relief  of  the  dyspnoea.  A  remarkable 
instance  of  this  condition  has  been  reported,  in  which  tracheotomy  was 
done  four  times  during  a  period  of  five  years.^  Associated  with  this  con- 
dition chronic  ulcers  are  almost  always  found.  These  ulcers  have  ragged 
and  thickened  edges  ;  frequently  vegetations  spring  from  them,  which  may 
reach  a  considerable  size,  even  to  the  degree  of  producing  aphonia  and  of 
impeding  respiration.  The  vocal  cords,  which  are  thickened  and  rough, 
are  very  often  the  seat  of  these  ulcers.  The  ventricular  bands  may  be  so 
swollen  as  to  overlap  the  cords.  The  vegetations,  which  may  grow  from 
the  margins  of  an  ulcer  or  from  other  portions  of  the  mucous  membrane, 
are  often  difficult  to  distinguish  from  simple  polypoid  growths.  Their 
favorite  seat  is  at  the  insertion  of  the  inferior  vocal  cords.  Ferras  states 
that  they  may  appear  in  the  ventricles  of  the  larynx,  where  natural  papillfE 
are  scanty.  The  history  of  the  case,  or  even  the  empirical  use  of  specific 
treatment,  may  sometimes  be  required  to  determine  their  character. 

Deep  Ulcerations Deep  ulcerations,  occurring  in  the  later  stages 

of  syphilis,  may  form  by  extension  from  the  pharynx  or  by  degeneration 
of  gummatous  deposit.  The  epiglottis  may  be  entirely  destroyed  by  the 
ulcerative  process.  Next  in  order  of  frequency  the  aryteno-epiglottic 
ligaments  are  attacked,  then  the  superior  vocal  cords,  and  more  rarely  the 
true  cords.  The  ulcerations,  especially  those  of  gummy  tumors,  are  very 
irregular  and  indurated.  Frequently,  vegetations,  like  those  occurring  in 
connection  with  the  ulcers  described  in  the  preceding  section,  accompany 
tliese  deep  ulcerations.  Extensive  regions  may  be  destroyed  in  a  chronic 
and  insidious  manner,  irreparable  injury  being  done.  These  ulcerations 
can  hardly  be  confounded  with  those  of  tubercular  origin,  which  are  smaller, 
more  numei'ous,  and  more  superficial.  The  lardaceous  base  and  the 
general  appearance  of  the  lesions,  in  connection  with  cicatrices  of  previous 
ulceration,  suggest  their  specific  character.  They  are  much  more  likely 
to  be  mistaken  for  malignant  disease.  In  cancer  the  tonsils  and  the  sub- 
maxillary glands  are.  at  an  early  period,  the  seat  of  infiltration.  Pain, 
often  extreme,  is  distinctive  of  cancer,  while  the  syphilitic  lesion  makes 
much  flower  progress  and  is  generally  painless,   until  the  tissues  have 

•  Tr.  Clin.  Soc.  Lond.,  vol.  x,  1877. 


622  AFFECTIONS    OF    THE    ORGANS    OF    RESPIRATION. 

been  extensively  destroyed.  In  most  cases  of  syphilis,  moreover,  there 
is  a  clear  history  of  infection,  and  traces  of  former  lesions  may  be  dis- 
covered in  the  mouth  or  pharynx,  or  in  other  regions  of  the  body. 

Gummy  Tumors Gummy  tumors  of  the  larynx  are  much  more  com- 
mon than  has  been  supposed.  Two  forms  of  gummatous  deposit  are  de- 
scribed by  Simyan  :^  a  cii'cumscribed  variety  of  a  grayish-red  color,  and 
a  ditFuse  infiltration  which  has  a  yellowish  color.  Virchow  describes 
gummy  tumors  of  the  larynx  as  extremely  vascular  nodules,  of  softer  con- 
sistence than  those  developed  in  other  regions,  which  gradually  ulcerate 
and  penetrate  the  deeper  tissues.  The  lesion  is  often  single,  and  may 
attain  a  very  large  size  ;  freciuently  the  tumors  are  small  and  multiple,  and 
may  be  limited  to  the  mucous  and  sub-mucous  tissues.  The  deposit  some- 
times undergoes  absorption,  but  more  frequently  it  degenerates,  forming 
the  deep,  ragged  ulcers  already  described,  which  may  involve  the  frame- 
work of  the  larynx  and  produce  permanent  deformity.  The  epiglottis 
and  the  arytenoids  are  most  often  involved,  but  any  of  the  laryngeal  car- 
tilao-es  may  suffer.  A  fatal  termination  may  ensue  in  the  course  of  these 
lesions  from  impediment  to  respiration,  due  to  the  size  of  the  tumor  or  to 
an  acute  oedema  of  the  larynx.  A  single  case  of  death  from  hemorrliage 
has  been  recorded  by  Tiirck. 

PEPaCHONDRiTis Perichondritis  is  generally  the  result  of  the  exten- 
sion of  an  inflammatory  or  ulcerative  process  from  the  mucous  and  sub- 
mucous tissues.  The  cartilage  itself  may  be  involved.  Pain,  of  a  marked 
character,  is  a  common  symptom  of  this  lesion,  and  the  parts  are  sensitive 
to  external  pressure.  Crepitation  on  paljjation  of  the  cartilage  is  referred 
to  by  Jullien^  and  others  as  a  sign  of  its  invasion.  Oedema  of  the  soft 
parts,  and  deformity  from  the  structural  changes  in  the  affected  cartilage 
are  frequently  observed.  The  epiglottis  and  the  arytenoid  cartilages  are 
most  often  involved,  more  rarely  the  cricoid.  They  may  be  entirely  dc= 
stroyed. 

Caries Caries,  or  true  necrosis,  in  cases  where  ossification  of  the 

cartilage  has  taken  place,  is  a  common  sequel  of  the  invasion  of  the  peri- 
chondrium by  inflammation  or  gummatous  ulceration.  It  is  always  a  very 
late  accident,  and  frequently  induces  structural  changes  in  the  larynx 
which  cannot  be  remedied.  An  instance  of  its  occurrence  six  years  after 
infection  has  been  reported  by  Lamalleree.^  Two  small  abscesses  formed 
on  the  anterior  aspect  of  the  neck  at  the  level  of  the  cricoid  cartilage. 
They  soon  opened,  and,  several  years  later,  pieces  of  necrosed  bone  were 
discharged  through  the  fistulous  tracks.  Fragments  of  sequestrum  may 
be  expectorated,  or  may  lodge  in  the  air-passages  and  cause  alarming  or 

'  Syphilis  laryiigee  tertiaire.     These  de  Paris,  1877. 

2  Mai.  v^neriennes,  Paris,  1879. 

3  Ann.  d.  mal.  de  I'oreille  et  du  larynx,  Par.  1878,  Vol.  IV.,  No.  5. 


THE    TRACHEA.  623 

even  fatal  dyspnoea.  The  occurrence  of  phlegmonous  inflammation  in  the 
parts  surrounding  the  larynx,  secondary  to  the  invasion  and  death  of  the 
cartilage,  has  been  made  the  subject  of  a  special  paper  by  Mauriac.^ 

Syphilitic  aphonia,  occurring  at  an  early  period,  without  appreciable 
lesions,  was  originally  described  by  Diday  before  the  use  of  the  laryngo- 
scope became  general.  There  can  be  little  doubt  that  the  condition  was 
really  due  to  lesions  which  could  not  be  discovered  with  the  impei'fect 
methods  of  exploration  at  his  command. 

Simyan  and  Paget^  describe  a  paralysis  of  the  vocal  cords,  which  has 
been  observed  in  the  later  stages  of  syphilis.  It  is  always  unilateral,  and 
affects  the  left  cord  more  often  than  the  right.  Simyan  gives  the  details 
of  a  case,  communicated  by  Libermann,  of  complete  aphonia  due  to  this 
condition,  which  appeared  eight  years  after  infection.  It  resisted  every 
kind  of  treatment,  until  its  specific  character  was  suspected,  when  the  use 
of  hypodermic  injections  of  mercury  was  begun.  The  affection  then 
yielded,  and  the  voice  was  gradually  restored. 

The  Trachea. 

The  trachea  may  be  the  seat  of  lesions  similar  to  those  occurring  in  the 
larynx.  Vierling^  concludes  from  the  observation  of  forty-six  cases  that 
early  syphilitic  lesions  are  rare ;  the  most  common  are  ulcerative  processes, 
which  lead  to  stenosis  by  contraction  of  the  resulting  cicatrices. 

The  wall  of  the  trachea  may  be  perforated  and  an  abscess  be  formed 
externally.  Usually  the  larynx,  trachea,  and  bronchi  are  involved  at  the 
same  time.  In  sixteen  out  of  the  forty-six  cases  the  larynx  was  spared. 
Cough,  purulent  expectoration,  and  dyspnoea,  which  may  be  intermittent, 
are  the  prominent  symptoms  of  tracheal  syphilis.  Stenosis  is  most  likely 
to  occur  just  above  the  bifurcation  of  the  trachea,  and  is  always  a  serious 
if  not  a  fatal  sequel  of  deep  ulceration.  Accoi'ding  to  Gerhardt,  stenosis 
of  the  trachea  may  be  distinguished  from  that  of  the  larynx  by  the  absence 
of  depression  of  the  larynx  during  convulsive  inspiration.  The  trachea 
above  the  ulceration  is  often  dilated,  and  the  structure  of  the  cartilages 
may  be  clianged  or  destroyed.  Thus  in  addition  to  the  stenosis  caused  by 
cicatricial  contraction,  the  ingress  of  air  may  be  impeded  by  collapse  ot 
the  trachea  at  each  act  of  inspiration. 

It  is  an  interesting  fact  that  stricture  of  the  air-passages  consequent 
upon  the  cicatrization  of  a  syphilitic  ulcer  may  cause  death  from  dyspnoea, 
so  that  specific  remedies  may  in  reality  hasten  a  fatal  termination  just  so 
far  as  they  exert  a  beneficial  influence  upon  the  local  disease.  Two  inter- 
esting cases  of  this  descri[)tion  are  given  in  the  Annuaire  de  la  syphilis 
(annee  1858,  p.  324). 

'  Sur  les  laryngopathies  sypli.  graves  compliqu6es  de  plilegmon  pcri-laryiigien, 
Paris,  1876. 

2  Deitparalysies  du  larynx.     These  de  Paris,  1877. 

3  Deutsches  Arch.  f.  klin.  Med.,  Leipz.,  April  16,  1878. 


624  AFFECTIONS    OF    THE    ORGANS    OF    RESPIRATION. 

In  the  first,  reported  by  Moissenet,  the  stricture  was  situated  just  above 
the  bifurcation  of  tlie  trachea.  The  lining  membrane  at  this  point  pre- 
sented a  honeycomb  appearance,  and  the  cartilages  were  more  or  less 
clianged  in  their  structure  and  destroyed ;  indeed,  four  of  the  rings  had 
entirely  disappeared  and  were  replaced  by  flexible  tissue  ;  hence,  in  addi- 
tion to  the  diminution  in  the  calibre  of  the  tube,  its  walls  collapsed  at  each 
act  of  inspiration  and  added  to  the  difficulty  in  the  ingress  of  the  air. 
The  patient  had  been  taking  mercurials  and  iodide  of  potassium  which 
only  aggravated  her  symptoms.  Tracheotomy  Avas  performed  without 
benefit,  since  the  larynx  was  unaff'ected  and  the  obstruction  was  below  the 
artificial  opening.     Death  was  caused  by  asphyxia. 

The  following  is  a  summary  of  the  second  case,  reported  by  M.  Demar- 
quay:— 

The  patient,  aged  3(5,  entered  a  maison  de  sante,  Oct.  25,  1858,  with 
all  the  symptoms  of  oedema  of  the  glottis.  He  seemed  to  be  threatened 
with  suffocation  ;  his  respiration  was  noisy  and  painful ;  he  had  had  a 
cough  for  two  months  with  slight  expectoration  ;  his  sputa  resembled  those 
of  laryngeal  phthisis  ;  and  he  had  lost  much  flesh.  For  a  fortnight  his 
symptoms  had  been  very  intense.  The  lungs  were  found  to  be  sound  ; 
and  as  the  patient  had  liad  ulcers  upon  the  penis  twelve  years  before,  fol- 
lowed six  years  afterwards  by  ulceration  and  perforation  of  the  soft  palate, 
iodide  of  potassium  was  ordered.  Under  this  treatment  he  continued  to 
improve  for  a  month  ;  but  on  Nov.  25th  he  was  suddenly  seized  with  such 
extreme  dyspnoea  that  M.  Demanjuay  thought  it  best  to  perform  ti'acheo- 
tomy.     The  operation  was  of  no  benefit  and  death  soon  ensued. 

At  the  autopsy,  the  larynx  was  found  to  be  perfectly  healthy,  with  the 
exception  of  a  small  cicatrix  between  the  two  arytenoid  cartilages ;  but 
the  trachea  was  found  to  be  abruptly  contracted  opposite  its  eleventh  ring, 
at  which  point  its  circumference  measured  only  28  millimetres.  This 
stricture  involved  the  left  side  of  the  trachea  and  was  formed  of  cicatricial 
tissue  in  which  six  rings  of  the  tube  were  twisted  on  themselves  and  frac^ 
tured.  Below  the  stricture  the  bronchi  were  dilated,  and  their  longitu- 
dinal muscular  fibres  hypertrophied.  The  lungs  were  healthy,  and  free 
from  tubercles. 

Treatment  op  Lesions  of  the  Larynx  and  Trachea. 

Treatment,  except  in  the  advanced  stages  of  laryngeal  syphilis,  gives 
prompt  and  permanent  results.  The  use  of  the  "  mixed"  treatment  is  in 
all  cases  indispensable,  and,  when  cacliexia  exists,  it  should  be  combined 
with  various  tonics.  Local  treatment  may  be  of  service  in  hastening 
reparation,  although  Krishaber  believes  that  it  is  not  essential,  except  in 
the  case  of  vegetations  or  of  liypertrophy  of  the  mucous  membrane.  For 
these  conditions  he  uses  cliromic  acid  and  the  galvano-cautery.  Acid 
nitrate  of  mercury,  chloride  of  zinc,  or  nitrate  of  silver  in  solutions  of 
appropriate  strength  may  be  applied  to  ulcerations.  Astringent  sprays, 
preferably  a  solution  of  sulphate  of  zinc,  sedative  insufflations,  such  as 


THE    BRONCHI.  625 

iodoform,  and  inhalations,  as  of  the  compound  tincture  of  benzoin,  are 
useful  palliatives.  When  (edema  threatens,  counter-irritation  externally 
is  indicated,  and  for  its  relief  scarification  of  tlie  mucous  membrane  may 
be  required.  Cohen^  speaks  of  the  oedema  wliich  sometimes  results  from 
the  use  of  large  doses  of  iodide  of  potash,  and  the  consequent  necessity  of 
closely  watching  the  eflcct  of  the  drug.  Spasm  may  be  quieted  with 
bromide  of  potassium,  and  opiates  may  be  required  in  the  rare  cases  of 
extreme  pain.  Fetor  of  the  breath  may  be  relieved  by  the  use  of  deter- 
gents and  disinfectants  in  the  form  of  sprays  or  gargles.  For  the  stenosis 
following  ulceration  dilatation  with  bougies  has  been  resorted  to  with 
results  not  fully  satisfactory ;  when  the  contraction  becomes  extreme  tra- 
cheotomy is  the  only  resource.  The  opei-ation  is  rarely  required  for  other 
conditions  which  cause  laryngeal  obstruction.  The  tracheal  lesions  of 
syphilis,  especially  those  which  may  result  in  stenosis,  are  much  more 
serious  tJian  similar  lesions  of  the  larynx.  Although  they  are  equally 
amenable  to  constitutional  treatment,  the  tracheal  lesions  are  usually  be- 
yond the  reach  of  surgical  intervention.  In  all  cases  of  syphilis  of  the 
air-passages,  and  especially  of  the  larynx,  particular  attention  should  be 
given  to  abstinence  from  tobacco  and  alcohol,  and  the  avoidance  of  exces- 
sive use  of  the  vocal  organs. 

The  Broxchi. 

The  bronchi  may  be  the  seat  of  syphilitic  ulceration  and  consequent 
stricture. 

In  the  case  of  Marguerite  Rudloff,  reported  by  Yirchow,  "  the  right 
bronchus  was  contracted  at  its  bifurcation  and  above  tliat  jioint ;  a  section 
of  it  presented  the  form  of  a  triangle ;  its  diameter  measured  a  quarter  of 
an  inch,  while  that  of  the  left  bronchus  measured  half  an  inch.  The  left 
bronchus  was  contracted  to  a  still  greater  extent  near  its  bifurcation,  but 
only  for  the  distance  of  a  quarter  of  an  inch,  and  was  adlierent  at  this 
point  to  the  normal  oesophagus  through  the  intervention  of  a  thick  and 
tendinous  mass  of  tissue.  Tlie  right  bronchus  was  the  seat  of  thickening 
and  contraction  whicli  extended  for  a  short  distance  into  its  brandies, 
which  further  on  were  reddened  iqion  their  internal  surface  and  dilated. 
Several  larger  dilatations  of  the  bronchi  were  found  in  tlie  inferior  lobe 
of  tlie  lung  which  was  otlierwise  healthy;  and  at  thes<^  points  tlie  pul- 
monary tubes  were  filled  with  mucus  and  surrounded  by  condensed  tissue 
which  extended  as  far  as  the  pleura." 

Yirchow  concludes  from  this  and  another  case  of  which  he  gives  an 
analysis,  that  "we  must  admit  the  existence  of  syphilitic  ulceration  and 
stricture  of  the  bronchi  similar  to  the  same  lesions  of  the  larynx,  and  must 
also  concede  that  syphilitic  bronchitis  may  give  rise  to  chronic  pneumonia, 
in  the  same  manner  as  laryngeal  idcerations  cause  extensive  induration  of 
the  cellular  tissue  of  the  neck.     I  have  often  seen  in  constitutional  syi»hilis, 

'  Diseases  of  the  Throat  and  Nasal  Passages.     Phila.,  1879. 
40 


^26  AFFECTIONS    OF    THE    ORGANS    OF    RESPIRATION. 

limited  star-shaped  cicatrices  of  the  pleura  and  the  sequela?  of  pleurisy,  in 
consequence  of  the  above-mentioned  changes."^ 

The  prognosis  in  syphilitic  ulceration  of  the  air-passages  is  exceedingly 
unfavorable.  Tiie  iodide  of  potassium,  mercurials,  nourishing  diet,  and 
tonics  may,  in  some  eases,  afford  relief,  while  in  others  they  prove  ineffi- 
cacious, or,  in  a  few  instances,  as  already  remarked,  may  hasten  a  fatal 
termination  by  inducing  cicatrization  of  the  ulcer  and  consequent  con- 
traction and  strichu-e.  Carmichael  believed  that  the  ulcerative  process 
was  maintained  by  the  transit  of  the  air,  and  that  tlie  best  method  of  cure 
was  the  early  performance  of  tracheotomy.  These  views  have  not,  how- 
ever, been  confirmed  by  recent  surgeons,  who  resort  to  tiiis  operation  only 
in  cases  of  impending  suffocation,  and  even  then,  since  the  stricture  may 
be  seated  below  the  artificial  opening,  if  for  no  other  reason,  the  prospect 
of  affording  relief  is  very  dubious. 

The  Lungs. 

Lancereaux  describes  an  interstitial  pneumonia  due  to  syphilis,  and 
also  gummy  tumors  of  the  lungs. 

Interstitial  Pneumonia — "  The  seat  of  this  change  is  variable  ;  some- 
times it  occupies  the  superior  or  middle  lobe  ;  at  other  times  it  is  limited 
to  the  inferior  lobe  ;  whence  we  may  conclude  that  it  may  invade  almost 
indiscriminately  the  different  portions  of  the  lungs,  without,  however,  ac- 
quiring a  very  considerable  extent.  The  affected  portion  of  the  paren- 
chyma is  firm,  hard,  elastic,  resistant  to  pressure,  friable,  impermeable  to 
air,  and,  therefore,  non-crepitant."  Numerous  yellowish  points  have  been 
observed  in  the  condensed  mass,  which  under  the  microscope  were  found 
to  be  composed  of  granular  nuclei  and  numerous  molecular  granules,  con- 
tained in  a  fibrous  network.  This  form  of  pneumonia  may  generally  be 
distinguished  by  the  small  extent  of  the  tissues  affected,  since  it  rarely 
involves  an  entire  lobe,  or  at  times  it  is  disseminated  at  various  points.  ' 

Gummy  Tumors — "  Their  number  is  variable,  sometimes  single,  but 
generally  multiple,  rarely  exceeding  six  or  eight.  They  appear  as  tumors 
of  a  grayish  or  yellowish-white  color,  somewhat  rounded,  of  the  size  of  a 
pea,  almond,  or  large  nut,  at  first  of  a  firm,  slightly  elastic  consistency, 
and  afterwards  rather  soft  and  cheesy  at  the  centre.  Deposited  in  the 
midst  of  the  parenchymatous  network,  these  tumors  are  generally  sur- 
rounded by  an  indurated,  fibrous,  and  grayish  tissue,  which  forms  a  kind 
of  cyst,  and  is  of  importance  in  the  diagnosis.  Upon  the  surface  of  a 
section  of  one  of  these  tumors,  this  cyst  or  zone  is  perfectly  distinct  from 
the  central  nodule  ;  the  former  is  resistant  under  the  finger,  evidently  tra- 
versed by  vessels,  and  is  made  up  of  j)erfectly  developed  fibrous  tissue ; 
the  latter  is  friable,  little  or  not  at  all  vascular,  formed  of  nuclear  elements 
or  imperfect  cells,  which  are  more  or  less  granular,  and  which  belong  to 
the  group  of  elements  of  connective  tissue."     Secondary  degeneration  of 

1  Op.  cit.,  p.  154. 


THE    LUNGS.  G27 

the  deposit  subsequently  commences  at  the  centre  and  extends  to  the 
periphery,  and  tlie  granulo-fatty  debris  may  be  absorbed  or  are  evacuated 
through  the  bronchi,  leaving  a  cavity  which  is  lined  by  the  fibrous  zone. 
Such  cavities  are  capable  of  cicatrization,  resulting  in  depressions  and 
scars  upon  the  surface  of  the  lungs,  which  have  often  been  mistaken  for 
those  of  tubercle. 

Both  this  form  and  the  one  before   described  are  often  attended  Avith 
dry  pleurisy,  followed  by  membranous  adhesions  to  the  costal  walls. 

The  most  important  recent  investigations  of  the  pulmonary  lesions  of 
syphilis  are  those  of  Drs.  Greenfield,  Goodhart,  Green,  Gowers,  Pye- 
8mith,and  Mahomed,  published  in  the  Transactions  of  the  London  Patho- 
loyical  Society  for  the  year  1877.  The  main  conclusion  of  these  observers 
is  that  syphilis  produces  fibroid  changes  in  the  lung,  especially  at  the  base 
and  in  the  middle  and  lower  lobes,  with  the  formation  of  nodules  of  a  new 
small  cell-growth ;  in  other  words,  granulation  tissue.  These  fibroid  de- 
posits may  consist  of  large  firm  bands  or  of  masses  of  greater  or  less  size. 
The  gummy  nodules  are  prone  to  gangrene,  and  their  vascularity  in  their 
early  stage  explains  the  haemoptysis  observed  in  syphilitic  subjects.  All 
observers  admit  that  the  minute  appearances  are  not  always  clearly  defined, 
since  both  tubercular  and  syphilitic  phthisis  are  accompanied  by  chronic 
inflammatory  changes  essentially  similar.  There  is,  however,  a  radical 
diffei'ence  between  the  two  diseases,  which  is  rendered  more  prominent  by 
their  clinical  features;  in  the  former  we  find,  coexisting  with  the  fibroid 
masses,  tubercles,  which  have  a  tendency  to  cheesy  degeneration,  while 
in  syphilitic  piithisis  there  coexist  small  cell-infiltrations,  which  have  a 
tendency  to  necrosis.  The  microscopic  appearances  of  the  syphilitic  lesion 
are  given  by  Dr.  Goodhart  as  follows :  There  is  thickening  of  the  bronchial 
septa  and  of  the  coats  of  the  vessels,  and  dilatation  of  the  bronchi.  The 
fibrous  septa  are  in  places  crowded  with  small  cells  and  nuclei,  which 
project  into  the  lung  tissue  between  the  alveolar  walls  which  they  distend. 
The  alveoli,  in  consequence,  become  contracted  and  are  ultimately  oblite- 
rated, leaving  a  fibro-nucleated  tissue  containing  vessels  of  moderate  size. 
Degenerative  changes  appear  to  be  going  on  in  the  central  parts.  "In 
one  patch  of  more  ra{)id  cell  growth  the  central  cells  were  softening  down 
into  cavities  without  any  previous  formation  of  fibrous  tissue."  The 
thickening  observed  in  the  outer  coats  of  the  arteries,  and  perhaps  also  in 
their  inner  coats,  was  not  out  of  proportion  to  the  general  thickening 
which  had  taken  place  in  the  bronchial  septa  and  around  all  of  the  tissues 
contained  in  them.  Dr.  Goodhart  states  that  in  some  cases  of  old  lung 
disease,  tubercular  grains  were  found  in  various  parts.  He  says:  "But 
while  I  do  not  wish  to  detract  from  such  an  occurrence  any  of  the  weight 
which  it  may  be  thought  to  have  against  the  disease  which  was  found 
along  with  it  being  essentially  syphilitic,  yet,  on  the  other  iiand,  it  must 
in  justice  be  remarked  that  the  presence  of  such  grains  in  the  lungs  is  no 
positive  evidence  of  their  tubercular  (as  we  understand  that  term)  nature. 
And'even  if  they  were  tubercles,  they  may  quite  possibly  have  arisen  in 
the  chronic  inflammatory  changes  whicli  resulted  from  the  syphilis;  and 


G28  AFFECTIONS    OF    THE    0RGAN8    OF    RESPIRATION. 

thougli  tubercles  were  found  in  tlie  lungs  in  six  cases,  yet  none  of  these 
were  prominently  tubercular,  but,  on  the  other  hand,  fibrous."  He  there- 
fore concludes  that,  "  with  the  large  proportion  of  cases  of  fibroid  disease 
of  all  the  cashes  of  chronic  lung  disease  which  occurred  in  syphilis,  there 
can,  I  think,  be  very  little  doubt  that  syphilis  and  fibrous  change  go 
together  in  the  lung  as  elsewhere."  As  to  tlie  natui-e  of  the  fibroid  lung 
disease,  whetiier  it  is  at  all  specific  or  only  a  i'orm  of  inflammation,  tuber- 
cular or  otherwise,  modified  by  the  syphilitic  virus,  he  says  :  "  On  this 
point  I  tiiink  there  can  be  very  little  hesitation  in  arriving  at  a  decision. 
I  can  see  no  ditference  in  any  of  the  sjiecimens  that  I  exhibit  between 
those  I  suppose  due  to  syphilis  and  the  more  chronic  forms  of  tubercular 
phthisis,  chronic  pneumonia,  and  miners'  phthisis  ;  all  of  these  are  histo- 
loo-ically  concerned  with  a  nuclear  growth  in  the  interstices  of  the  lungs. 
They  are  indeed  but  varying  forms  of  inflammation,  but,  unless  we  think 
to  find  a  specific  corpuscle  in  syi)hilis,  the  close  similarity  of  the  growths 
which  occur  in  it  to  those  of  other  diseases  was  but  to  be  expected,  since 
the  range  of  variation  in  the  arrangement  of  cells  and  tissue  and  in  the 
form  of  cells  is,  so  far  as  we  know,  most  limited."  Although  he  believes 
that  the  changes  are  characteristic  of  syi)hilis,  he  can  determine  no  histo- 
logical distinction.  •'  Fibroid  degeneration  of  the  lungs  due  to  syphilis 
diflers  from  chronic  pneumonia  and  that  state  of  solidity  which  arises  after 
contraction  of  the  lung  from  old  pleurisy,  in  that  it  is  generally  less  evenly 
spread  over  the  lobe  than  they  ;  it  is  nodular  rather  than  diff"use,  and  is 
symmetrical  and  not  unilateral ;  it  differs  from  miners'  phthisis  in  wanting 
the  extreme  amount  of  dilatation  of  the  tubes  and  possessing  more  solidity 
from  fTi-euter  cell  growth.  Many  of  the  patches  of  disease  look,  it  is  true, 
not  unlike  red  or  gray  hepatization,  but  they  are  more  tough,  generally 
less  granular,  and  often  somewhat  translucent." 

The  clinical  features  of  syphilitic  affections  of  the  lungs  have  been 
carefully  studied  by  Fournier,  Rollett,  and  Frey.  Fournier'  thinks  that 
syphilis  affects  the  lungs  in  two  ways:  first,  by  the  development  of  it:r 
specific  lesions  — gummata,  etc.  ;  second,  by  producing  changes  such  as 
occur  in  any  cachexia.  The  lesions,  which  seldom  occur  before  the  tertiary 
period,  are  divided  by  Fournier  into  two  classes:  1,  simple  hyperplasia; 
2,  gummous  infiltration.  Syphilitic  hyperjdasia  of  the  lung  is  similar  to 
that  of  the  liver.  The  septa  of  the  lung  are  thickened  and  the  alveoli 
consequently  narrowed.  The  epithelial  lining  is  secondarily  involved. 
Fournier  regards  the  process  as  really  an  interstitial  pneumonia,  which 
results  in  the  formation  of  nodular  masses.  In  recent  cases  the  pleura 
over  the  nodules  is  white  and  glistening ;  in  old  cases  stellar  depressions 
of  the  membrane  are  found. 

Gummata  of  the  lungs  resemble  those  of  other  organs.  There  may  be 
a  single  tumor,  and  the  lesions  rarely  exceed  six  or  eight  in  number,  in 
this  respect  differing  from  tubercles,  which  are  very  numerous.  They  are 
usually  superficial  and  occupy  the  lower  lobes.  They  degenerate  from  the 
centre,  leaving  a  cavity  with  white,  hard,  and  fibrous  walls.     Fournier 

'  FocENiEK,  Gaz.  hebd.  de  med.,  Paris,  Nos.  48,  49,  51,  1875. 


THE    LUNGS.  629 

enumerates  five  anatomical  points  of  distinction  between  gumma  and 
tubercle  of  the  lungs :  1.  Situation — tubercle  involves  the  upper  lobe  of 
each  lung;  gumma,  one  lung  to  a  limited  degree.  2.  Number — gummata 
are  few  and  solitary;  tubercles  become  confluent.  3.  Gummata  are  larger, 
and  are  never  miliary.  4.  Color — gummata  are  white  or  yellow,  never 
transparent  like  miliary  tubercle.  5.  Consistency — the  structure  of  the 
gumma  is  more  uniform,  and  if  it  breaks  down  its  capsule  prevents  the 
degeneration  from  being  complete. 

Syphilitic  lesions  of  the  lungs  may  attain  quite  a  large  size,  with  very 
obscure  symptoms.  There  may  be  some  disturbance  of  respiration  and 
slight  cough  with  scanty  expectoration.  Physical  signs  are  absent,  unless 
the  lesion  be  very  superficial  and  circumscribed.  The  dyspna-a  gradually 
increases,  but  is  never  very  intense,  the  cough  becomes  more  severe  and 
spasmodic,  the  expectoration  is  free  and  muco-purulent,  and  haemoptysis 
may  occur.    The  symptoms  are  in  fact  similar  to  those  of  ordinary  phthisis. 

Fournier  recognizes  three  varieties  of  syphilitic  affections  of  the  lungs  : 
the  latent,  in  wliich  the  lesions  are  circumscribed,  cause  no  symptoms, 
and  are  not  detected  until  after  death  ;  in  the  second  variety  there  is 
merely  slight  disturbance  of  respiration  without  any  disorder  of  the  general 
condition,  the  symptoms  being  those  of  limited  induration  or  of  a  cavity  ; 
the  third  is  a  severe  form,  [)resenting  all  the  features  of  phthisis.  The 
prognosis  depends  upon  the  extent  of  the  lesions  and  their  amenability  to 
treatment.  That  cure  may  be  effected  has  been  proved  by  the  post-mortem 
discovery  of  the  traces  of  gummous  deposits  which  have  been  reabsorbed. 
The  gradual  disappearance  of  the  physical  signs  of  induration,  with  im- 
provement in  the  general  condition,  as  a  result  of  treatment,  is  often 
observed.  The  remarkable  degree  to  which  subjects  of  these  lesions  some- 
times retain  their  flesh  and  strength  should  always  excite  suspicion  of 
syphilis.  It  is  the  opinion  of  Fournier  that,  however  grave  and  extensive 
the  lesions  may  be,  the  disease  will  yield  to  specific  treatment. 

The  views  of  Rollet^  are  of  interest  chiefly  by  reason  of  their  contrast 
with  those  of  Fournier.  RoUet  thinks  that  syphilis  of  the  lungs  is  indi- 
cated by  pronounced  dyspnoea  or  even  orthopnoea,  besides  a  sense  of 
ojipression  or  pain  on  deep  inspiration.  The  cough  is  at  first  dry  or  ac- 
companied by  bloody  sputa.  Percussion  shows  a  sharply  de{in<'-d  region 
of  dulness  over  the  middle  lobes,  particularly  on  the  anterior  and  lateral 
portions.  Auscultation  gives  at  first  diminished  respiratory  sounds,  and 
finally  the  usual  signs  of  phthisis.  He  alludes  to  the  statement  of  Gran- 
didier,  that  in  twenty-seven  cases  the  affection  involved  the  middle  lol)e 
of  the  riglit  lung,  and  adds  that  conclusions  should  not  be  drawn  without 
confirmation  of  the  fact.  He  admits  the  diagnostic  value  of  tlie  fact  that 
the  upper  lobes  generally  escape.  The  history  of  the  case  is  of  the  greatest 
importance,  and  the  coexistence  of  syphilitic  lesions,  the  absence  of  a 
jihthisical  tend<aicy,  and  improvement  under  specific  treatment  are  points 
in  the  diagnosis. 

'  RoLLET,  Ueber  Lungensyphilis,  Wien.  med.  presse,  No.  47,  1875. 


630  AFFECTIONS    OF    THE    ORGANS    OF    CIRCULATION. 


CHAPTER    XVIII. 
AFFECTIONS   OF   THE    ORGANS    OF    CIRCULATION. 

The  Heart. 

The  heart  may  be  attacked  by  syphilis  in  two  forms,  either  as  a  diffuse 
myocarditis,  or  as  a  gummatous  deposit.  Clianges  in  the  muscuLir  fibre 
of  the  heart  analogous  to  amyloid  degeneration  of  the  liver,  but  not  neces- 
sarily characteristic  of  syphilis,  may  also  occur. 

Diffuse  Myocarditis Diffuse  or  interstitial  myocarditis  is  described 

by  Lancereaiix  as  follows  :  "At  first,  the  appearance  of  rounded  nuclei  in 
the  thickness  of  the  sarcolemma  or  in  the  connective  tissue;  the  forma- 
tion of  cells  and  fibres  of  connective  tissue;  vascularity;  then  at  some 
points  fatty  metamorphosis  of  the  nuclear  and  cellular  elements,  whence 
arises  the  yellowish  coloration  ;  at  the  same  time  and  secondarily  to  the 
formation  of  connective  material,  granulo-fatty  degeneration  of  the  mus- 
cular fibres,  the  contents  of  which  may  be  completely  absorbed."  This 
form  generally  coexists  with  gummy  tumors  in  the  heart. 

GuaiMATA Gummy  tumors  of  the    heart  vary  greatly   in   size  and 

number.  One  has  been  observed  as  large  as  an  eg^^,  but  they  seldom 
exceed  the  size  of  a  cherry.  They  may  appeal'  in  any  portion  of  the  mus- 
cular tissue  of  the  heart,  but  are  most  commonly  found  in  the  wall  of  the 
left  ventricle.  Jullien  has  collected  nineteen  cases  of  gummatous  myJ- 
carditis,  four  of  which  occurred  in  women.  The  time  after  infection  at 
which  the  disease  apj)eared  varied  from  the  first  to  the  eighteenth  year. 
In  the  majority  of  cases  the  affection  is  coincident  with  the  late  lesions  of 
syphilis.  An  interesting  case  of  the  precocious  development  of  cardiac 
syphilis,  in  which  the  autopsy  was  made  by  Prof.  Loomis,  was  reported  to 
the  N.  Y.  Pathological  Society  in  February,  1876.  The  patient  died 
with  double  pleurisy  and  pericarditis.  The  muscular  tissue  of  the  heart, 
which  was  enlarged  and  dilated,  was  almost  entirely  replaced  by  inter- 
stitial cellular  deposit.  The  external  evidences  of  syphilitic  infection  did 
not  appear  until  several  weeks  after  the  manifestation  of  cardiac  and  pul- 
monary sym|)toms.      Renal  and  hepatic  lesions  were  also  present. 

In  structure  gummata  of  the  heart  resemble  similar  lesions  elsewhere. 
They  differ  from  sarcomata,  with  whose  cellular  structure  they  are  almost 
identical,  in  their  tendency  to  cheesy  degeneration.  Tubercular  deposit 
is  always  associated  with  similar  lesions  of  the  lungs.  These  tumors  are 
almost  always  attended  by  more  or  less  inflammation  of  the  surrounding 
tissues.     Under  the  microscope  small  cells  are  seen  scattered  among  the 


THE    BLOODVESSELS.  631 

muscular  fibres,  which  may  themseh'es  be  granular ;  frequently  the  striaj 
are  destroyed.  The  heart  is  enlarged  and  dilated,  and  pulmonary  con- 
gestion frequently  results  from  its  impaired  action. 

Gummatous  tumors  of  the  heart  seldom,  if  ever,  soften  and  evacuate 
their  contents.  On  the  contrary,  they  remain  dry  or  undergo  caseous 
degeneration,  while  their  peripheral  tissues  become  dense  and  indurated, 
and  slowly  contract. 

The  endocardium  overlying  these  tumors  is  almost  invariably  inflamed 
and  thickened.  Sometimes  it  becomes  much  roughened  and  so  dense  as 
to  be  almost  cartilaginous.  Vegetations,  like  small  condylomata,  often 
spring  from  its  affected  surface,  especially  near  and  upon  the  valves. 
These  conditions  must  obviously  interfere  with  the  current  of  blood,  and 
may  lead  to  the  formation  of  emboli. 

The  i:)erlcardium  may  also  become  inflamed,  and  covered  with  false 
membrane.  Its  cavity  may  be  completely  obliterated.  Its  surface  has 
been  found  studded  with  miliary  granules,  and  Lancereaux  has  reported  a 
case  in  which  a  gummy  tumor  as  large  as  a  cherry  was  embedded  in  the 
thickened  pericardium. 

The  symptoms  of  cardiac  syphilis  may  be  obscure  or  absent.  In  many 
cases  the  heart's  action  is  feeble  and  irregular;  palpitation,  dyspnoea,  cyano- 
sis, and  ffidema  are  sometimes  observed.  Pain  or  a  sense  of  oppression  in 
the  prajcordium  may  be  complained  of.  Examination  may  show  hyper- 
trophy of  the  heart,  and  a  murmur  may  possibly  be  detected  on  ausculta- 
tion. In  many  cases,  however,  the  diagnosis  must  be  furnished  by  the 
general  history. 

The  prognosis  is  always  unfavorable,  although  a  cure  has  been  reported 
in  three  cases,  and  doubtless  the  condition  has  been  entirely  overlooked  in 
many  others.  Death  is  usually  sudden,  and  may  be  due  to  embolus,  to 
cardiac  spasm,  or  to  syncope.  A  fatal  i*esult  may  also  ensue  from  second- 
ary complication  of  the  lungs,  by  which  perfect  aeration  of  the  blood  is 
interfered  with.  In  two  of  the  cases  collected  by  Jullien,  death  was  pre- 
ceded by  hemiplegia. 

The  treatment  comprises  the  use  of  iodide  of  potash,  tonics,  and  stimu- 
lants. 

The  Bloodvessels. 

The  veins  and  capillaries  are  very  rarely  invaded  by  syphilis.  Two 
cases  of  gummy  tumor  seated  in  ti»e  connective  tissue  external  to  the 
saphena  vein  have  been  reported  by  Gosselin.  The  syphilitic  lesions  of 
the  arteries  may  be  consecutive  to  disease  of  the  surrounding  tissue  or 
they  may  be  primary.  Lesions  of  the  latter  class  are  found  almost  ex- 
clusively in  the  small  arteries  of  the  brain.  In  a  few  cases  the  carotid 
has  been  attacked.  The  morbid  change  consists  of  a  circumscribed  thick- 
ening of  the  wall  of  the  vessel  by  an  infiltration  of  small  cells,  especially 
into  the  tunica  intima.  The  lesion  is  limited  internally  by  the  endothe- 
lium, and  externally  by  the  membrana  fenestrata.     The  cells  are  round 


632 


AFFECTIONS    OF    THE    ORGANS    OF    CIRCULATION. 


and  spindle-shaped,  and  seem  to  become  developed  into  an  imperfectly 
fibiillated  tissue.  The  tunica  adventitia  is  abnormally  vascular  and  infil- 
trated with  cells,  the  infiltration  usnally  invading  the  muscular  coat  also. 
The  changes  in  the  arterial  wall  are  well  shown  in  the  accompanying 
figure,  taken  from  Green's  pathology. 


Fijr.  121. 


Tfe, 


mis^ 


Syphilitic  disease  of  cerebral  arteries. 


This  arterial  lesion  has  been  studied  especially  by  Lancereaux,  who 
regards  it  as  quite  distinct  from  atheroma,  and  in  the  cerebral  arteries  by 
Heubner,  Greenfield,  and  Barlow.  The  affection  differs  from  simple  arte- 
ritis in  three  particulars  ;  it  is  limited  to  the  small  vessels,  it  is  developed 
rapidly,  and  it  involves  all  the  coats  of  the  vessel.  The  disease  may  termi- 
nate by  the  formation  of  a  thrombus,  in  consequence  of  the  obstruction  to 
the  vascular  current,  or  the  new  cells  may  be  absorbed,  leaving  the  wall 
of  the  vessel  so  thin  and  weak  that  it  becomes  dilated  or  even  ruptured. 

The  symptoms  of  the  lesion  of  course  depend  upon  its  seat.  When  tiie 
carotid  is  involved  there  is  impairment  of  the  cerebral  functions,  pain  in 
the  head,  epileptiform  attacks  and  perhaps  coma  and  death.  When  the 
disea^se  attacks  the  cerebral  arteries  the  nervous  phenomena  are  usually 
more  marked.  The  headache  is  severe  ;  paralysis,  with  or  without  coma, 
supervenes ;  aphasia  and  muscular  spsusms  are  observed.  Amendment 
may  take  place,  or  delirium  with  fever  and  epileptiform  convulsions  may 
be  developed,  and  a  fatal  result  rapidly  follows. 

The  relation  of  syphilis  to  aneurism  of  the  large  arteries  is  a  question 
of  great  interest.  Although  the  influence  of  the  specific  virus  in  its  pro- 
duction may  have  been  overestimated,  there  seems  to  be  good  reason  to 
believe  that  aneurism  does  occur  in  syphilitic  subjects  as  a  direct  result  of 
specific  changes  in  the  arterial  wall. 


SYPHILITIC    ORCHITIS.  G33 


CHAPTER   XIX. 

SECONDARY   AND   TERTIARY   AFFECTIONS   OF 
THE   GENITO-URINARY   ORGANS. 

Syphilitic  Epididymitis. 

Under  the  name  of  svpliilitic  epididymitis,  Dron,'  in  1863,  described 
an  affection  limited  to  tlie  globus  major  of  the  testis. 

In  some  cases  this  affection  begins  insidiously  and  is  not  recognized  until 
"  a  lump"  is  felt  by  the  patient;  in  others,  a  slight  uneasiness  attends  its 
formation.  Upon  examination,  we  find  a  small,  round,  or  oval  tumor  just 
above  the  testis,  the  scrotum  itself  being  unaffected.  It  usually  has  a 
smooth  surface  and  is  of  a  decidedly  firm  consistency.  Its  size  varies  from 
that  of  a  pea  to  a  lima  bean.  It  may  exist  in  one  epididymis  only,  but 
frequently  both  are  affected.  Such  tumors  remain  in  an  indolent  condition 
without  showing  any  tendency  to  degeneration,  and  they  always  promptly 
disappear  under  mercurial  treatment.  Other  portions  of  tlie  epididymis  or 
the  testicle  itself  are  commonly  not  attacked  simultaneously.  We  have, 
however,  seen  two  instances,  and  Fournier  has  met  with  such,  in  which 
the  globus  minor  was  involved  shortly  after  the  globus  major.  We  have 
also  found  similar  tumors  developed  in  the  cord  subsequent  to  the  ap})ear- 
ance  in  the  epididymis  ;  and  others  again  in  which  sarcocele  coexisted. 

Thisafi^ection  is  usually  a  somewhat  precocious  manifestation  of  syphilis, 
occurring  in  most  cases  within  the  first  six  months  and  sometimes  as  early 
as  the  second  month,  or  again  as  late  as  the  fifth  year  after  infection.  It 
is  more  commonly  unilateral  when  it  occurs  at  a  late  period.  In  oi)position 
to  the  view  that  it  is  the  result  of  acute  or  chronic  urethral  inflammation, 
it  is  only  necessary  to  say  that  it  occurs  in  syphilitic  subjects,  some  of 
whom  have  never  had  any  urethral  trouble  and  that  it  is  quickly  cured  by 
anti-syphilitic  treatment.  Fournier  aptly  remarks  that  probably  many 
cases  of  syphilitic  epididymitis  liave  been  wrongly  diagnosticated  as  tuber- 
cular. An  important  point  in  the  diagnosis  of  this  affection  is  that  as  a 
rule  it  attacks  the  globus  major,  whereas  in  gonorrlucal  epididymitis  the 
globus  minor  is  most  commonly  involved  alone. 

Sypiulitic  Ouonrns. 

A  disease  of  the  testicle,  dependent  upon  syphilis,  was  recognized  by 
Astruc,^  who  speaks  of  its  indolent  character,  and  contrasts  it  with    the 

'  De  I'epididyraite  syphilitique  ;  Arch.  gen.  do  lued.,  Paris,  1863. 
2  Book  III.  chap.  iv. 


G34  AFFECTIONS    OF    THE    GENITO- URINARY    ORGANS. 

acute  inflammation  of  gonorriKjeal  testicle  ;  it  was  unknown  to  Hunter, 
but  was  noticed  by  Bell.'  and,  more  recently,  has  been  descril^ed  by  Sir 
Astley  Cooper,'-  Berard,^  Yeljteau,*  and  others,  but  our  present  knowledge 
of  this  affection  is  chiefly  due  to  Ricord,  who  has  given  a  most  faithful 
descri[)tion  of  its  symptoms,  pathology,  and  treatment,  under  the  name  of 
syphilitic  albuginitis. 

Sy[)hilitic  sarcocele,  orchitis,  or  albuginitis,  as  it  is  variously  termed, 
is  one  of  the  so-called  transition  symptoms  of  syphilis,  on  the  confines 
between  secondary  and  tertiary  lesions,  but  more  closely  allied  to  the 
latter  than  the  former.  When  the  constitutional  disease  runs  a  rapid 
course,  it  may  sometimes  occur  as  early  as  the  fourth  or  fifth  month  after 
contagion,  while  secondary  symptoms  are  still  present ;  but,  in  the  majority 
of  cases,  it  does  not  appear  until  several  years  after  the  primary  sore,  and 
is  accompanied  by  well-marked  tertiary  manifestations  in  the  fauces,  peri- 
osteum, or  bones ;  or,  in  some  instances,  it  stands  alone  as  the  only  evidence 
that  the  patient  is  still  affected  with  the  syphilitic  poison. 

Symptoms.-^— In  most  cases,  syphilitic  orchitis  attacks  both  testicles 
either  at  the  same  time  or  consecutively.  Its  symptoms  ai*e  deserving  of 
special  attention,  since  it  may  readily  be  confounded  with  other  affections 
of  the  testis  which  require  extirpation.  The  records  of  surgery  show  that 
many  testicles  have  been  removed  for  what  is  now  known  to  be  an  essen- 
tially curable  disease. 

One  of  the  most  characteristic  features  of  this  affection  is  the  almost 
entire  absence  of  pain  attending  it,  and  the  great  insensibility  to  pressure; 
w^henever,  therefore,  a  testicle  becomes  enlarged  without  any  of  the  ordi- 
nary signs  of  inflammation,  in  a  person  who  lias  once  had  syphilis,  there 
is  strong  reason  to  suspect  that  the  disease  is  due  to  syphilitic  taint.  In 
exceptional  instances,  a  dull  pain  is  felt  about  the  loins,  but  generally  the 
onl}^  uncomfortable  sensation  is  a  feeling  of  weight  in  the  affected  organ,^ 
which  is  worse  towards  evening  after  the  patient  has  been  upon  his  feet 
during  the  day,  but  which  does  not  undergo  the  nocturnal  exacerbation  so 
common  to  syphilitic  pains  situated  in  the  periosteum  and  bones.  More- 
over, as  the  disease  progresses,  the  testicle  appears  to  lose  even  its  normal 
sensibility,  and  may  be  roughly  handled  without  causing  the  slightest 
uneasiness. 

The  body  of  the  testicle,  which  is  commonly  alone  affected,  is  somewhat 
increased  in  size,  but  never  to  the  same  extent  as  in  encephaloid  disease 
of  the  same  organ ;  and  it  rarely  exceeds  twice  its  normal  diameter. 
Ricord  was  in  the  habit  of  saying  at  his  lectures,  "Whenever  you  meet 
with  a  tumor  of  the  testis  as  large  as  your  fist,  and  find  that  the  swelling 
is  not  in  a  great  measure  due  to  effusion,  you  need  not  suspect  syphilis." 

'  Treatise  on  Gonorrhoea  Virulenta  and  Lues  Venerea,  vol.  ii.  p.  128. 
2  Structure  and  Diseases  of  the  Testis. 

*  Des  divers  engorgements  du  testicule,  Paris,  1834. 

*  Dictionnaii-e  de  med. 


SYPHILITIC    ORCHITIS.  635 

In  most  cases,  a  small  portion  of  the  apparent  swelling  is  dependent  upon 
hydrocele;  since  in  nearly  every  instance  of  syphilitic  orchitis,  there  is  a 
slight  effusion  into  the  tunica  vaginalis.  When  the  amount  of  fluid  is 
considerable,  it  may  be  necessary  to  evacuate  it  by  puncture  with  a  broad 
needle,  before  a  satisfactory  examination  can  be  made;  but  in  most  cases, 
we  may  by  firm  pressure  sufficiently  displace  the  fluid  to  reach  the  body 
of  the  testicle  and  determine  its  condition  by  palpation.  At  an  early 
stage  of  the  disease,  the  testicle  may  be  found  to  contain  one  or  more  dis- 
tinct masses  of  induration,  which  form  slight  projections  upon  the  surface, 
of  the  size  of  the  head  of  a  pin,  pea,  or  even  an  almond,  but  which  are 
never  so  prominent  as  to  change  the  general  contour  of  the  organ.  These 
projections  are  due  to  an  eflTusion  of  plastic  material,  of  the  same  nature  as 
gummy  tumors,  upon  the  surface  of  the  tunica  albuginea.  As  the  disease 
progresses,  the  distinct  masses  of  induration  coalesce  and  form  a  hard 
resistant  tumor,  which  still  preserves  to  a  great  extent  the  normal  shape 
of  the  testicle. 

In  rarer  instances,  the  tumor  is  smootli  throughout  its  whole  course, 
while  the  other  symptoms  remain  the  same. 

The  course  of  this  affection  is  exceedingly  slow  and  chronic,  frequently 
lasting  for  several  years.  The  sexual  desires  are  not  changed,  unless  the 
disease  has  made  great  progress  in  both  testicles. 

When  recognized  at  a  sufficiently  early  period,  syphilitic  orchitis  may 
almost  invariably  be  arrested,  and  the  organ  restored  to  its  original  in- 
tegrity. If  left  to  itself  it  most  frequently  terminates  in  obliteration  of 
the  seminifei'ous  tubes,  and  complete  or  partial  atrophy,  corresponding  to 
the  extent  of  tlie  adventitious  deposit;  or,  again,  the  parenchyma  of  the 
gland  may  degenerate  into  fibrous,  cartilaginous,  or  even  osseous  tissue. 
Ricord  lias  laid  down  the  law  that  suppuration  never  takes  place  in  un- 
complicated sypliilitic  orchitis,  and  has  shown  that  many  supposed  cases 
to  the  contrary  were  really  instances  of  tubercular  disease  of  the  testis,  or 
gummy  tumors  of  the  cellular  tissue  of  the  scrotum.  This  law  was  gene- 
rally admitted  as  correct,  and  was  not  for  a  time  called  in  question;  but 
RoUet'  reported  an  unquestionable  instance  of  this  disease  in  which  the 
substance  of  the  testicle  protruded  through  an  ulceration  of  the  scrotum 
and  the  tunica  vaginalis  and  albuginea,  giving  rise  to  the  condition  known 
as  fungus  of  the  testicle  ;  and  also  quotetl  a  similar  case,  witnessed  by 
himself,  from  Jarjavay  and  referred  to  another  described  by  Curling,^ 
Victor  de  Meric*  reported  still  another  instance  of  fungus  of  the  testicle 
dependent  upon  syphilis.  It  would  appear,  therefore,  that  Ricord's  law  is 
not  without  exception. 

Pathological  Anatomy Tliis  affection  is  found  to  exist  in  two 

forms,  the  diffused  and  the  circumscribed. 

'  Aiimiaire  cle  la  syiili.,  aiiii<5o  1848,  p.  90. 

2  On  the  Testis,  2(1  .'.I.  p.  277. 

3  Lancet,  Loiad.,  Am.  ed.,  May,  1859. 


G3G  AFFECTIONS    OF    THE    GENI  TO- URIN  AR  Y    ORGANS. 

Diffused  FoDii. — In  tlie  earliest  stage  nothing  is  discovered  but  an 
increase  in  the  vasciihxrity  of  the  organ.  Soon  adventitious  nuclei  and 
cells  appear  in  the  connective  tissue,  and  are  followed  by  fibrous  bands 
which,  starting  from  the  internal  surface  of  the  tunica  albuginea,  permeate 
the  body  of  the  testicle,  and  cause  compression  and  atrophy  of  the  tubuli 
seminiferi,  the  epithelial  cells  of  which  undergo  fatty  degeneration,  and 
are  stained  of  a  brownish  color  by  the  de|)0sit  of  pigment.  The  organ  is, 
at  the  outset,  somewhat  larger  than  normal,  and  hard  and  resistant  to  the 
touch  ;  but,  in  the  absence  of  treatment,  atrophy  is  the  usual  termination, 
eitiier  general  if  the  inflammation  is  diffuse,  or  presenting  a  cicatricial  de- 
pression when  only  a  portion  of  the  gland  lias  been  affected. 

The  tunica  albuginea  is  often  thickened  ;  the  tunica  vaginalis  contains 
a  certain  amount  of  serous  fluid,  its  walls  become  covered  with  false  mem- 
branes, and  often  contract  adhesions  with  each  other. 

Circumscrihed  Form In    this  form,  gummy  material   is   deposited  in 

masses  from  the  size  of  a  pea  to  that  of  an  English  walnut,  sometimes 
scattered  through  the  testicle,  at  others  aggregated,  and  often  surrounded, 
especially  at  a  late  stage,  by  a  fibrous  capsule.  This  deposit  originates 
from  the  external  (muscular)  coat  of  an  artery,  or  from  the  membrane  of 
a  seminal  tubule.  Its  color  is  grayish  or  yellowish-white  ;  its  consistency 
somewhat  firm  towards  the  circumference,  but  soft  towards  the  centre;  its 
histological  elements  vary  in  different  cases,  being  sometimes  entirely 
fibrous,  at  other  times  consisting  of  cells  and  nuclei,  or  amorphous  matter 
mixed  with  fatty  crystals. 

The  tendency  of  these  masses  is  to  undergo  secondary  degeneration  and 
softening,  which  commences  at  the  centre,  so  that  a  section  frequently 
exhibits  several  layers  varying  in  consistency.  As  a  consequence  of  this 
degeneration,  inflammation  of  the  surrounding  tissues  may  take  place, 
ulcerations  of  the  adherent  layers  of  the  tunica  vaginalis  ensue,  and  a  por- 
tion of  the  deposit  projecting  through  the  0])ening  gives  rise  to  the  syphi- 
litic fungus  of  the  testicle  described  by  UoUet  and  others. 

Lancereaux  figures  a  case  in  which  both  testicles  were  almost  entirely 
composed  of  a  homogeneous  yellowish  sul)stance  resembling  the  yolk  of  a 
well-boiled  egg;  the  tunica  albuginea  had  undergone  the  same  transfor- 
mation, and  was  distinguisliable  only  in  spots  from  the  general  mass. 

Tlie  circumsci'ibed  form  of  syphilitic  testicle  often  coexists  with  the 
diffuse. 

Diagnosis Syphilitic  orchitis  may  be  confounded   with  gonorrhocal 

epididymitis,  with  cancer,  tubercular  disease  of  the  testis,  or  chronic 
orchitis. 

Gonorrhoeal  inflammation  of  the  testis  is  an  acute  disease,  attended  with 
severe  pain,  difficulty  of  motion,  redness,  heat,  and  tension  of  the  scrotum  ; 
chiefly  attacking  the  epididymis;  often  complicated  with  inflammation  of 
the  vas  deferens;  preceded  or  accompanied  by  a  discharge  from  the  ure- 
thra ;  and  yielding  to  simple  treatment.     The  induration  left  by  an  acute 


SYPHILITIC    ORCHITIS.  637 

attack  of  swelled  testicle  may  be  recognized  by  the  previous  history  of  the 
case,  and  by  being  limited  to  the  globus  minor  of  the  epididymis. 

In  cancer  of  the  testicle,  which  is  genei-ally  of  the  encephaloid  variety, 
the  pain  is  slight  at  the  commencement,  but  increases  with  the  progress  of 
the  disease  and  becomes  very  severe  and  lancinating;  the  tumor  is  very 
irregular,  grows  with  great  rapidity,  and  often  attains  an  immense  size; 
and  tiie  cord  and  neighboring  ganglia  are  frequently  involved.  "  If  you 
remove  a  cancerous  testicle,  the  disease  almost  always  returns  in  the  cord ; 
in  a  second  attack  of  syphilitic  orchitis,  the  opposite  testicle  is  affected."^ 

Tubercular  disease  of  the  testis  occurs  about  the  age  of  puberty  rather 
than  in  adult  life,  and  in  subjects  presenting  evidences  of  a  strumous  dia- 
thesis. The  adventitious  deposit  first  takes  place  in  the  epididymis,  or  in 
the  centime  and  not  in  the  external  portions  of  the  testis  as  in  syphilitic 
orchitis ;  as  the  disease  progresses,  slight  protuberances  may  be  formed 
upon  the  surface  as  in  the  last-mentioned  disease,  but  they  soon  contract 
adhesions  with  the  tunica  vaginalis  and  scrotum,  suppurate  and  ulcerate. 
Moreover,  evidences  of  tubercular  deposit  may  often  be  detected  in  the 
vesiculfe  seminales  by  examination  with  the  finger  per  anum,  or  in  the 
cord  and  inguinal  ganglia. 

Great  diversity  of  opinion  exists,  especially  between  English  and  French 
surgeons,  relative  to  the  frequency,  nature,  and  symptoms  of  chronic 
orchitis.  Mr.  Curling,  who  may  be  taken  as  the  representative  of  English 
views,  regarded  this  affection  as  quite  common,  and  dependent  upon  a 
deposit,  generally  in  circumscribed  masses,  of  a  peculiar  yellow  homo- 
geneous substance  in  the  body  of  the  testicle,  which  frequently  terminates 
in  suppuration  and  benign  fungus  of  the  testis.  Among  the  French, 
Nelaton  maintains,  justly,  I  think,  that  this  description  applies  to  true 
tubercular  testis,  and  that  Curling  has  also  included  under  the  head  of 
chronic  orchitis  many  cases  of  syphilitic  albuginitis.  He  believes,  with 
the  generality  of  French  surgeons,  that  chronic  orchitis  is  an  exceedingly 
rare  affection  ;  that  it  is  due  to  plastic  inflammatory  infiltration,  bearing 
no  resemblance  to  tubercle,  in  the  substance  of  the  epididymis  and  body 
of  tlie  testicle,  not  circumscribed  in  well-defined  masses,  often  very  per- 
sistent, but  capable  of  absorption  without  suppuration  ;  that  it  often  origin- 
ates in  irritation  about  the  deeper  portions  of  the  urethra,  and  sometimes 
gives  rise  to  a  very  peculiar  condition  of  the  sperm,  which  is  of  a  reddish 
color,  resembling  thin  currant  jelly.* 

It  is  unnecessary  to  enter  more  minutely  into  the  details  of  the  differ- 
ential diagnosis  between  syphilitic  orchitis  and  the  above  mentioned  dis- 
eases. If  attention  be  paid  to  their  prominent  features  as  now  described, 
especially  when  assisted  by  a  knowledge  of  the  history  of  the  case  and  a 
careful  search  for  coexisting  sypliilitic  symptoms  or  traces  of  their  pre- 
vious existence,  the  surgeon  will   not  often  be  left  in  doubt.     If  any  un- 

'  Dl'puytre.x,  Le(}ons  orales  de  diiiique  cliirurgicale,  2e  ed.,  t.  iv.,  p.  230. 
2  Gaz.  d.  H6p.,  No.  14,  1857. 


638  AFFECTIONS    OF    THE    GENITO-UKTNARY    ORGANS. 

certainty  exist,  the  patient  should  always  have  the  benefit  of  a  trial  of 
specific  remedies  before  resorting  to  operative  procedures. 

Treatment In   the  treatment  of  this  disease  Ricord  relies  almost 

exclusively  upon  iodide  of  potassium,  administered  in  doses  of  from  five 
to  thirty  grains  three  times  a  day.  It  would  appear  that  Ricord  is  here 
somewhat  inconsistent  with  his  own  doctrines,  since  he  elsewhere  recom- 
mends a  mixed  treatment  consisting  both  of  iodide  of  potassium  and 
mercury  in  the  transition  symptoms  of  sy[)hilis,  among  which  he  ranks 
syphilitic  orcliitis.  In  my  own  practice,  I  have  been  dissatisfied  with  the 
iodide  of  potassium  alone  and  have  obtained  much  more  favorable  results 
from  its  combination  with  mercury.  For  instance,  in  a  case  under  my 
care,  the  patient  had  been  taking  ten  grains  of  the  iodide  three  times 
a  day  during  two  months  for  a  tubercular  syphilitic  eruption,  when  my 
attention  was  first  called  to  the  affection  of  the  testicle,  which  had  eitlier 
appeared  or  certainly  had  not  improved  during  the  treatment.  The 
dose  of  the  remedy  was  gradually  increased  to  twenty  grains  three  times 
a  day  without. affecting  the  orchitis,  which  speedily  improved  atter  substi- 
tuting half  a  grain  of  the  protiodide  of  mercury  for  the  iodide  of  potassium 
taken  at  noon,  and  continuing  the  latter  remedy  morning  and  night.  In 
many  cases,  and  especially  in  broken-down  constitutions,  it  is  better  to 
employ  mercurial  inunction  together  witli  the  iodide  of  potassium  and 
tonics  internally. 

Local  treatment  is  of  secondary  importance,  and,  in  most  instances,  may 
be  entirely  dispensed  with,  except  that  the  testicles  should  be  relieved  of 
their  own  weight  by  a  suspensory  bandage.  Judging  from  the  case  re- 
ported by  Rollet,  even  a  fungoid  growth  of  the  testicle  projecting  through 
an  ulceration  of  the  scrotum,  will  disappear,  and  cicatrization  take  place 
under  the  use  of  constitutional  remedies  alone.  The  local  treatment 
commonly  recommended,  and  which  perhaps  in  a  few  cases  may  be  em- 
ployed with  advantage,  consists  in  daily  mercurial  inunction  upon  thS 
scrotum,  or  compression  by  means  of  stra[)s  of  adhesive  plaster,  as  in 
swelled  testicle  from  gonorrhoea.  The  effusion  into  the  tunica  vaginalis  is 
in  most  cases  soon  absorbed  under  general  treatment,  but  if  excessive,  may 
be  evacuated  by  means  of  a  lancet  or  broad  needle.  The  danger  of  wound- 
ing the  swollen  testis  is  too  great  to  admit  of  tlie  use  of  a  trocar  as  in  the 
ordinary  method  of  ta[)[)ing  for  hydrocele. 

Affections  of  the  Vasa  Deferentia,  the  Vesicula:  Seminales, 
AND  THE  Prostate. 

The  vas  deferens  is  usually  intact  in  cases  of  syphilitic  orchitis,  but  in  a 
few  rare  instances  has  been  known  to  be  consecutively  involved.  Verneuil' 
met  with  a  gummy  tumor  of  the  cord  as  large  as  the  two  fists,  extending 

'  Bull.  Soc.  auat.  de  Par.,  2e  Serie,  t.  ler,  1856. 


AFFECTIONS    OF    THE    PENIS.  639 

into  the  iliiic  fossa,  of  firm  consistency,  and  the  seat  of  dull  pain  ;  the  pa- 
tient had  a  similar  deposit  in  the  right  auricle  of  the  heart. 

No  instance  of  disease  of  the  vesicalce  seminales  dependent  upon  syphilis 
has  as  yet  been  reported. 

Neither  is  anything  definite  known  of  the  liability  of  the  prostate  to  be 
attacked  by  the  later  manifestations  of  syphilis,  although  Lancereaux  re- 
gards such  occurrence  as  probable,  and  states  that  our  knowledge  on  this 
point  lias  been  obscured  by  the  confusion  existing  until  comparatively  a 
recent  period  between  gonorrhoea  and  syphilis. 

Affections  of  the  Penis. 

I  have  already  spoken  of  a  number  of  cases  occurring  in  my  own  prac- 
tice, of  what  proved  to  be  a  deposit  of  syphilitic  tubercle  in  the  penis, 
especially  near  tlie  furrow  at  the  base  of  the  glans,  and  readily  mistakable 
for  a  chancroid.     (See  "  Diagnosis  of  the  Chancroid.") 

According  to  Ricord,  such  deposits  may  also  take  place  in  the  coi'pora 
cavernosa.  He  says  :  "  A  small  hard  point  sometimes  appears  in  one  or 
both  corpora  cavernosa  of  a  patient  in  the  tertiary  stage  of  syphilis.  The 
patient,  without  previous  pain  or  other  appreciable  symptom,  suddenly 
discovers  a  slight  hardness  of  the  size  of  a  millet  seed  in  the  substance  of 
the  penis.  This  gradually  inci'eases  in  size,  either  on  one  or  both  sides, 
without  showing  any  preference  for  any  one  point  of  the  corpora  cavernosa 
over  another ;  thus  we  find  it  eitlier  above  or  below,  or  on  either  side. 
The  progress  of  the  disease  is  slow  and  without  pain,  but  soon  the  penis 
begins  to  deviate  fi-om  a  straight  line,  and  presents  the  following  peculiari- 
ties :  if,  for  example,  there  is  induration  of  only  one  cavernous  body,  the 
erectile  tissue  loses  its  permeability  at  the  point  indurated  ;  if  the  pa- 
tient has  an  erection,  the  corpus  cavernosum  on  the  healtliy  side  alone  be- 
comes turgid  ;  tiie  opposite  body  remains  in  a  state  of  flaccidity,  and  the 
penis  has  a  lateral  curvature  ;  the  erection  might  be  called  an  inguino- 
crural  one,  since  the  extremity  of  the  penis  points  to  the  fold  of  the 
groin. 

"  If  the  induration  occupies  the  dorsum  of  the  penis,  tlie  latter  forms  an 
arc  of  a  circle  with  its  concavity  upwards,  the  glans  approximating  to  the 
symphysis  pubis.  I  have  seen  every  variety  of  this  affection  and  have 
even  met  with  patients  in  whom  the  penis  formed  a  complete  ring." 

It  is  well  to  mention  that  these  symptoms  are  not  always  due  to  syphi- 
lis; I  have  known  of  several  instances  in  which  they  were  produced  by  in- 
jury to  the  penis  in  a  state  of  erection,  and  others  still  in  which  the  cause 
was  not  appreciable,  and  in  whicli  anti-syphilitic  remedies  failed  to  afford 
the  slijjrhtest  relief. 


g40  affections  of  the  genito-uri n  ary  organs. 

Affections  of  the  Ovaries,  Fallopian  Tubes,  Uterus,  and 

Vagina. 

Syphilitic  affections  of  the  ovaries  are  rarely  met  with.  According  to 
Lancereaux,  they  present  a  close  analogy  to  syphilitic  affections  of  the 
testicle,  and  are  either  diffuse  or  circumscribed.  This  author  lias  only  met 
with  the  diffuse  fV)rm  after  it  has  arrived  at  the  stage  of  atrophy  ;  the 
ovaries  were  of  the  usual  size,  or  smaller  than  natural,  fibrous  in  their 
structure,  with  scattered  cicatrices  and  destitute  of  Graafian  vesicles,  al- 
though the  patients  had  not  yet  arrived  at  the  usual  age  for  the  cessation 
of  the  menses.  Lancereaux  gives  a  representation  of  a  case  furnished  by 
Dr.  Kichet,  in  which  there  was  a  circumscribed  deposit  of  gummy  material, 
similar  to  that  found  in  syphilitic  orchitis.  The  symptoms  of  these  affec- 
tions are  said  to  be  a  slight,  dull  pain  in  the  region  of  the  ovaries,  possibly 
at  the  outset  some  increase  in  the  size  of  these  organs,  perceptible  on  ab- 
dominal and  vaginal  palpation,  a  loss  of  sexual  })assion  and  sterility.  It 
is  evident  that  these  signs,  taken  in  connection  with  the  history  of  the 
case,  can  only  furnish  a  probability  of  the  nature  of  the  disease,  which  may 
be  further  increased  by  the  success  of  anti-syphilitic  treatment. 

No  instance  is  known  in  which  the  Fallopian  tubes  have  been  affected 
with  syphilis. 

Certain  cases  in  which  uterine  tumors  in  syphilitic  subjects  have  yielded 
to  the  internal  administration  of  iodide  of  potassium  and  mercurials,  render 
it  probable  that  this  organ  is  not  exempt  from  the  late  manifestations  of 
sypliilis,  but  nothing  more  definite  is  known  upon  the  subject,  since  post- 
mortem investigation  has  been  wanting. 

Exulcerative  Hypertrophy  of  the  Neck  of  the  Uterus. 

Our  limited  knowledge  of  this  affection  is  derived  chiefly  from  the 
wi'itings  of  Henry,  Aime  Martin  and  De  Fourcauld.  It  consists  in  a  total' 
or  {)artial  enlargement  and  hardening  of  the  os,  which  appears  congested 
and  is  more  or  less  superficially  ulcerated ;  its  surface  is  granular  or  often 
presents  a  varnished  aspect.  The  hypertrophy  is  greatest  in  the  trans- 
verse diameter  and  is  but  slight  in  the  antero-posterior.  The  parts  are 
indurated  and  resistent,  or  sometimes  doughy,  and  generally  are  not  sensi- 
tive to  manipulation.  In  most  of  the  cases  there  were  no  symptoms 
referrible  to  the  utero-ovarian  system  ;  in  others  the  patients  complained 
merely  of  certain  unpleasant  sensations,  such  as  pain  in  the  loins,  back  and 
thighs,  and  a  bearing-down  feeling.  The  secretion  from  the  ulcer  is 
scanty,  and  muco-purulent,  and  is  contagious  like  the  secretion  from  other 
secondary  lesions.  The  affection  may  be  accompanied  by  various  dis- 
placements of  the  womb. 

According  to  A.  Martin  this  lesion  occurs  in  48  per  cent,  of  syphilitic 
women,  beginning  on  an  average  in  fifty-eight  days  after  infection,  while 
in  the  three  cases  reported  by  Henry  it  was  developed  in  the  second, 
eighth,  and  ninth  years  of  syphilis.     According  to  the  former  observer  it 


AFFECTIONS    OF    THE    KIDNEYS.  641 

is  frequently  preceded  by  fever,  and  in  thirty-one  cases  out  of  forty-seven 
it  coexisted  with  hypertropliy  of  the  tonsils.  It  runs  a  chronic  course  but 
yields  readily  to  internal  treatment  alone.  Martin,  who  observed  its 
cure  in  from  four  to  five  weeks,  considers  local  treatment  of  merely  sec- 
ondary importance. 

We  know  nothing  positive  of  the  pathology  of  this  affection.  Its  usual 
occurrence  in  the  early  months  of  syphilis  and  the  frequent  coexistence  of 
hypertrophy  of  the  tonsils  suggest  the  idea  of  hypersemia  with  perhaps 
slight  cell  infiltration.  Its  curability  also  favors  this  opinion,  while  all 
the  facts  oppose  the  view  of  its  being  gummy  infiltration. 

This  affection  is  important  not  only  in  the  matter  of  diagnosis  but  also 
as  explaining  certain  cases  of  syphilitic  infection  in  men,  after  connection 
with  women  who  are  found  to  be  free  from  vulvar  lesions. 

There  is  probably  no  reason  why  the  vagina  should  not,  like  other 
mucous  canals,  be  affected  by  the  deposit  of  syphilitic  tubercle  in  the  sub- 
mucous cellular  tissue,  and  undergo  subsequent  contraction,  but  no  instance 
of  the  kind  has  been  recorded. 

Affections  op  the  Kidneys. 

M.  Rayer  was  the  first  to  trace  a  connection  between  the  form  of  Bri^ht's 
disease,  known  as  waxy  degeneration,  and  syphilis,  and  this  subject  has 
since  been  investigated  by  several  observers,  especially  by  Frerichs,  Vir- 
chow,  and  Lancereaux. 

I  have  myself  met  with  a  number  of  instances  of  albuminuria  in  persons 
suffering  with  syphilitic  cachexia,  but  have  had  no  opportunity  for  post- 
mortem examination.  In  one  case,  complicated  with  ascites,  I  was  obliged 
to  tap  the  patient  on  three  occasions  ;  the  symptoms  yielded  for  a  time 
under  full  doses  of  iodide  of  potassium  and  mercurial  inunction,  but  death 
ensued  a  short  time  after  the  patient  had  passed  from  under  my  obser- 
vation. 

Yirchow  attributes  the  albuminuria  of  syphilitic  subjects  to  amyloid  or 
waxy  degeneration  of  the  kidneys,  presenting  nothing  specific  in  its  char- 
acter, but  common  to  all  forms  of  cachexia. 

Lancereaux  recognizes  the  same  forms  as  are  met  with  in  other  organs; 
the  interstitial  inflammatory  form,  the  gummy  form,  and  cicatrices  the 
result  of  the  preceding  forms.  Of  twenty  cases  of  visceral  syphilis  ob- 
served by  him,  there  were  four  of  interstitial  nephritis  (twice  with  waxy 
degeneration) ;  one  of  small  gummy  tumoVs;  several  of  cicatrices  upon  the 
surface  with  atrophy. 

"  Diffuse  Form,  Interstitial  Nephritis This  change  in  the  kidneys  is 

characterized  by  a  new  formation  of  the  constituent  elements  of  the  stroma. 
At  the  outset,  the  appearance  of  nuclei  of  connective  tissue,  and  multi- 
plication of  the  cellular  element ;  in  some  cases  fatty  degeneration  of  the 
new  products.  The  kidneys,  of  average  consistency,  present  a  smooth, 
pale  surface,  scattered  with  fine  striae  and  slightly  yellowish  spots.  Later, 
they  are  firmer  than  natural ;  their  capsule  is  thickened  and  their  surface 
41 


G42  AFFECTIONS    OF    THE    GENITO-URIN AR Y    ORGANS. 

mammilluted ;  their  size  is  at  first  normal  or  exaggerated,  but  they  grad- 
ually become  atrophied  in  virtue  of  the  tendency  of  the  tissue  of  new 
formation  to  contract,  and,  according  to  the  greater  or  less  extent  of  the 
nephritis,  this  atrophy  will  be  general  or  partial.  In  one  case,  the  cortical 
substance  was  only  two  millimetres  in  thickness,  the  columns  of  Bertin 
■were  small  and  atrophied,  and  the  whole  medullary  substance  was  of  a 
yellowish  and  lardaceous  appearance.  Consecutive  to  the  changes  in  the 
stroma,  an  alteration  occurs  in  the  active  elements  of  the  kidneys.  The 
Malpighian- corpuscles,  compressed  by  the  connective  tissue,  are  soon  atro- 
phied, and  several  of  our  observations  make  mention  of  this  atrophy 
together  with  adhesion  of  the  capsule  to  the  renal  parenchyma.  The  epi- 
thelium gradually  undergoes  fatty  degeneration.  In  addition  to  this  form 
of  degeneration,  we  sometimes  find  amyloid,  lardaceous,  or  waxy  degene- 
ration, which  partially  obstructs  the  diminution  in  volume;  but  the  latter  is 
always  an  indirect  alteration  similar  to  that  occurring  in  cirrhosis  of  the 
liver  due  to  syphilis." 

With  regard  to  the  diagnosis  of  this  form,  and  that  produced  by  the 
abuse  of  alcoholic  stimulants,  Lancereaux  says:  "Interstitial  parenchy- 
matous inflammation  due  to  the  immoderate  use  of  spirituous  liquors  is 
more  genei'al ;  it  leads  to  more  complete  atrophy,  and  does  not  usually 
occasion  upon  the  surface  of  the  organ  the  deep  and  cicatricial  depressions 
of  syphilitic  inflammation." 

Circumscribed  Form,  Giimmy  Tumors Gummy  tumors,  though  rare, 

still  exist  in  the  kidneys  as  in  other  organs.  In  one  of  Lancereaux's  cases, 
upon  the  surface  of  the  kidneys  and  in  the  thickness  of  the  cortical  sub- 
stance, were  found  small  tumors  of  the  size  of  a  pea,  of  firm  consistency, 
of  a  yellowish  color,  and  presenting,  under  the  microscope,  the  usual  cel- 
lular and  nucleolar  elements  of  gummy  deposit. 

Cicatrices  u])on  the  surface  of  the  kidneys  are  the  result  of  the  advanced 
sta<ye  of  the  preceding  forms,  and  are  due  to  the  absorption  of  the  normal^ 
elements  of  these  organs.  "  They  present  a  strong  resemblance  to  tlie  de- 
pressions and  cicatrices  which  succeed  hemorrhagic  deposits,  but  the  latter 
may  be  recognized  by  the  ordinary  integrity  of  the  fibrous  capsule,  and 
the  presence  of  the  coloring  matter  of  the  blood.  They  stand  in  some 
relation  to  the  bloodvessels,  and  are  constantly  associated  with  disease  of 
the  heart." 

Syphilitic  affections  of  the  kidneys  may  be  attended  or  not  with  albumi- 
nuria. In  the  latter  case,  the  prognosis  is  not  necessarily  serious  ;  in 
the  former  the  contraiy  holds  good,  the  usual  symptoms  produced  by 
uremia  may  ensue,  and  although  the  affection  is  usually  of  long  duration, 
the  termination  is  commonly  fatal,  and  death  often  takes  place  suddenly 
from  coma. 


AFFECTIONS    OF    THE    NERVOUS    SYSTEM.  643 


CHAPTER    XX. 
AFFECTIOXS    OF    THE    NERVOUS    SYSTEM. 

No  department  of  syphilos^aphy  has  been  studied  so  extensively  and 
so  tlioi'ouglily,  within  the  past  ten  years,  as  that  rehiting  to  the  eflfects  of 
syphilis  upon  the  cerebro-spinal  axis.  Syphilitic  nervous  affections  are 
very  numerous,  and  are  now  generally  conceded  to  be  of  frequent  occur- 
rence. Our  knowledge  of  them  has  been  extended,  and  facility  and  cer- 
tainty in  their  diagnosis  increased  by  numerous  monographs  and  reports 
of  cases  which  have  been  published,  especially  during  the  last  five  years. 

Our  limited  space  compels  us  to  describe  these  affections  briefly,  and 
we  shall  be  unable  to  refer  in  detail  to  the  writings  of  various  authors. 

Syphilitic  nervous  affections  may  be  develoi)ed  as  early  as  the  sixth 
raontli  and  as  late  as  the  twentieth  year  after  infection. 

They  are  seen  more  frequently  in  men  than  in  women,  and  are  most 
common  between  the  ages  of  twenty  and  thirty,  simply  because  syphilis 
is  most  likely  to  be  contracted  at  this  period  of  life.  It  seems  to  be  an 
established  fact  that  nervous  phenomena  are  likely  to  follow  a  course  of 
syphilis  in  which  the  external  manifestations  have  been  insignificant,  or 
so  sligiit  as  to  have  been  entirely  overlooked. 

Syphilis  does  not  primarily  attack  nervous  tissue,  but  begins  in  sur- 
rounding or  investing  structures.  For  instance,  lesions  of  the  meninges, 
or  of  the  bones,  induce  softening  or  induration  of  the  brain.  These  lesions 
are  peculiar  in  tlieir  distribution  ;  they  rarely  involve  an  entire  hemi- 
sphere, or  all  parts  of  any  particular  region ;  they  are  limited  in  extent 
and  unsymmetrically  arranged.  Thus,  one  hemisphere  may  be  involved 
in  two  places,  and  there  may  also  be  a  lesion  of  the  cord,  or  the  surface 
of  the  brain  may  be  attacked  at  the  same  time  with  one  or  more  of  the 
large  cerebral  arteries,  and,  as  a  result,  irregular  and  incongruous  nervous 
symptoms  are  exhibited.  Associated  with  hemiplegia,  there  may  be  optic 
neuritis,  mydriasis,  or  paralysis  of  one  of  the  cranial  nerves,  or  even  para- 
plegia. 

The  brain  is  more  frequently  attacked  than  the  spinal  cord.  Our 
knowledge  of  the  effect  of  syphilis  upon  the  cerebellum  is  very  limited. 

The  prominence  and  constancy  of  some  of  the  nervous  phenomena  of 
syphilis  enables  us  to  recognize  them  as  distinct  affections,  namely,  sub- 
acute meningitis,  hemiplegia,  epilepsy,  paraplegia,  and  aphasia,  and  cer- 
tain others  of  minor  importance. 


g44  affections  of  the  nervous  system. 

Predisposing  Causes  of  Syphilis  of  the  Nervous  System. 

Nervous  symptoms  are  especially  likely  to  appear  in  persons  of  a  neurotic 
or  neuropathic  constitution,  which  may  be  hereditary  or  acquired.  Cliorea, 
migraine,  apoplexy,  melancholia,  and  neuralgia  are  common  features  in 
the  family  history  of  such  individuals.  Those  who  have  previously  had 
some  simple  nervous  atfection  are  particularly  liable,  when  infected  by 
syphilis,  to  the  development  of  specific  nervous  symptoms.  Protracted 
mental  anxiety,  depressing  emotions,  sexual  excesses,  the  abuse  of  alco- 
hol and  of  narcotics,  have  been  known  to  act  as  predisposing  causes.  Of 
diseases,  those  accompanied  or  followed  by  cerebral  congestion,  also  malaria 
and  other  conditions  producing  cachexia,  may  act  indirectly.  Sunstroke 
and  injuries  of  the  skull  may  be  included,  as  well  as  the  gouty  diathesis, 
particularly  in  elderly  persons  and  in  those  in  whom  gouty  cerebral  symp- 
toms have  been  prominent. 

The  inadequacy  or  the  absence  of  treatment,  in  relation  to  the  invasion 
of  the  nerve  centres  by  syphilis,  should  be  observed.  In  reading  the 
histories  of  cases  thus  far  reported,  it  is  found  that  in  many  no  treatment 
at  all  had  been  attempted,  in  some  the  treatment  had  been  insufficient, 
while  in  very  few  had  it  been  carried  to  the  extent  which  we  deem  neces- 
sary in  even  the  slightest  cases. 

The  nervous  phenomena  of  syphilis  genei-ally  originate  in  lesions  devel- 
oped in  one  or  more  of  the  following  structures : — 

1.  The  Cranial  Bones  and  Vertebra. 

2.  The  Dura  Mater. 

3.  The  Arachnoid  and  Pia  Mater. 

4.  The  Brain  and  Cord. 

5.  The  Arteries. 

6.  The  Nerves. 

Affections  of  the  Bones. 

Any  lesion  seated  on  the  inner  surface  of  the  cranium  or  vertebras,  may 
excite  inflammation  of  the  membranes,  and  may  finally  lead  to  morbid 
changes  in  the  brain  itself  and  in  the  spinal  cord.  The  most  frequent 
lesions  are  nodes,  exostoses,  caries,  and  necrosis. 

Although  nodes  may  occur  early  in  the  course  of  syphilis,  these  ai"e 
generally  considered  tertiary  lesions.  In  one  instance  we  have  seen  mul- 
tiple nodes  developed  on  the  external  surface  of  the  cranium,  ten  months 
after  syphilitic  infection  ;  the  presumption  is  that  similar  growths  may 
appear  as  early  on  the  inner  surface.  We  may,  therefore,  expect  grave 
disturbance  of  the  nervous  system  during  the  first  year  and  as  late  as  the 
twentieth,  since  syphilitic  osseous  lesions  are  known  to  be  developed  even  at 
this  advanced  period.  The  phenomena  may  be  referred  to  pressure,  or  to 
inflammation  of  the  brain  substance,  and  are  of  the  most  varied  character, 
including  paralyses,  convulsions,  ataxic  symptoms,  and  mental  disturbances. 


AFFECTIONS    OF    THE    ARACHNOID    AND    PIA    MATER.  645 

Cases  have  been  observed,  in  which  extensive  destruction  of  the  skull 
bones  has  occurred,  even  with  partial  loss  of  the  dura  mater,  without  the 
production  of  cerebral  symptoms. 

A  remarkable  case,  reported  by  Gama,  in  which  there  was  destruction 
of  the  bones  of  the  face,  including  the  ethmoid,  caries  of  the  frontal 
bone,  erosion  of  the  dura  mater,  disorganization  of  the  arachnoid,  and 
localized  superficial  softening  of  the  anterior  hemispheres,  which  were 
bathed  in  pus,  presented  as  the  single  nervous  symptom,  severe  pain  in  the 
head. 

It  is  interesting  to  notice  that  large  portions  of  the  cerebral  mass  in  the 
anterior  basal  region,  which  was  the  part  involved  in  the  foregoing  case, 
have  been  removed  in  surgical  operations  for  injury,  without  producing  any 
bad  symptoms. 

The  membranes  of  the  brain  may  be  the  seat  of  hypernemia,  which  pro- 
duces no  permanent  alteration,  or  the  process  may  become  chronic  and 
result  in  structural  changes. 

Affections  of  the  Dura  Mater. 

The  dura  mater,  being  a  fibrous  membrane,  is  peculiarly  susceptible  to 
the  syphilitic  influence.  The  changes,  which  usually  consist  of  thickening 
due  to  increased  cell-growth,  roughening  of  the  inner  surface  of  the  mem- 
brane and  abnormal  vascularity,  are  generally  not  striking.  In  some 
cases  the  membrane  has  a  brownish-red  color  and  gelatinous  appearance, 
yet  its  structure  remains  firm. 

The  extent  of  the  structure  involved  and  the  amount  of  thickening  vary, 
but  are  generally  considerable. 

The  dura  mater  may  be  exclusively  affected,  or  the  disease  may  invade 
the  inner  table  of  the  skull  and  the  arachnoid,  or  the  dura  mater  may  be 
secondarily  affected  by  processes  beginning  in  the  arachnoid  and  pia  mater. 
In  the  case  of  nodes  of  the  inner  table,  the  dura  mater  is  found  thickened 
and  abnormally  adlierent. 

The  syphiloma  may  form  a  circumscribed  tumor,  or  may  be  diflTused 
over  a  large  area. 

In  his  atlas,  Lancereaux^  gives  an  excellent  illustration  of  gummatous 
infiltration  into  the  dura  mater. 

The  portion  of  tlie  membranes  enveloping  the  brain  is  more  often  in- 
volved than  that  covering  other  parts.  Tliere  may  be  but  one  focus  of 
disease,  or  several  ;  in  tlie  latter  case  they  are,  as  a  rule,  unsymmetrical. 

Syphilomata  of  the  s[)inal  dura  mater  have  an  origin,  and  pursue  a  course, 
similar  to  those  of  the  cerebral. 

Affections  of  the  Arachnoid  and  Pia  Mater. 

In  simple  hyperaemia  of  the  pia  malcr,  the  arachnoid  may  not  be  in- 
volved, but  when  the  process  advances  to  cell-i)roliferati()n  it  is  impos- 
sible to  demonstrate  a  line  of  demarcation  between  the  two  membranes. 

'  Atlas  d'anatomie  patliologi(iue,  pi.  41,  Paris,  1874. 


6-16  AFFECTIONS    OF    THE    NERVOUS    SYSTEM. 

In  most  cases,  the  affection  of  these  membranes  consists  of  congestion 
and  visible  enhirgement  of  tiie  vessels,  followed  by  increase  of  connective 
tissue  and  consequent  thickening ;  but  sometimes  gummatous  infiltration 
supervenes,  constituting  a  gummous  meningitis. 

More  or  less  change  in  the  subjacent  nervous  tissue  always  follows, 
and  the  lesion  may  involve  the  dura  mater  and  the  cranial  bones. 

This  is  perhaps  the  most  frequent  syphilitic  nervous  lesion.  It  is  found 
in  single  or  multiple  patches,  distinctly  circumscribed,  of  round  or  oval 
shape  and  of  various  sizes. 

When  multiple,  the  patches  are  scattered  irregularly,  most  frequently  at 
the  base,  in  the  anterior  and  middle  fossa?,  less  frequently  on  the  con- 
vexity of  the  brain,  seldom  on  the  cord  and  medulla,  and  exceptionally  on 
the  cerebellum. 

Affections  of  the  Brain  and  Cokd. 

The  changes  in  the  brain  and  cord  are  always  secondary  to  lesions  of 
the  bones,  of  the  meninges,  or  of  the  vessels,  and  consist  of  two  kinds  of 
softening,  the  red  and  the  white,  which  are  similar  to  these  lesions  when 
non-specific. 

The  softening  is  likely  to  be  more  superficial  when  the  lesion  begins  in 
the  meninges,  than  when  it  originates  in  the  bones. 

A  primary  vascular  lesion  on  the  basal  surface  will  produce  much  more 
serious  and  extensive  structural  change  in  the  brain  than  one  at  the  vertex, 
for  the  reason  that,  in  the  latter  situation,  the  vessels  anastomose  freely, 
whereas,  in  the  former,  each  vessel  is  distributed  to  a  region  which  has  no 
other  source  of  nutrition. 

Affections  of  the  Arteries. 

Although  the  effect  of  Syphilis  upon  the  cerebral  arteries  has  been 
referred  to  by  several  English  authors,  our  knowledge  of  the  subject  was 
meagre  and  unsatisfactory  until  the  appearance  of  the  excellent  mono- 
grajdi  by  Ileubner,  in  which  he  gives  a  minute  description  of  the  various 
morbid  changes. 

These  changes,  which  are  chiefly  sub-endothelial,  consist  of  thickening 
of  the  lamellaj  of  tlie  endothelium,  between  which  and  the^membrana 
fenestrata  is  soon  deposited  a  finely  granular  substance,  with  a  few  nuclei, 
some  in  process  of  division,  as  well  as  a  few  nucleated  spindle-shaped  and 
stellate  cells.  In  the  normal  condition  this  part  is  nearly  free  from  cells 
and  nuclei. 

Subdivision  and  fresh  proliferation  of  cells  constitute  the  subsequent 
changes.  An  important  point  of  distinction  between  atheroma  and  the 
syphilitic  process  is,  that,  in  the  latter,  tlie  development  of  cells  is  more 
active  than  that  of  intercellular  substance. 

As  the  process  continues,  the  endothelium  becomes  separated  from  the 
raembi'ana  fenestrata,  tlie  interposed  cells  become  compressed  and  flattened, 


AFFECTIONS    OF    THE    ARTERIES.  647 

and,  by  their  fusion,  probably  result  in  the  formation  of  giant  cells.  The 
endothelium  becomes  tliickened,  and  encroaches  on  the  lumen  of  the  vessel. 
Owing  to  the  irritation  produced,  small  round  cells,  perhaps  derived  from 
the  vasa  vasorum,  are  observed.  While  the  essential  lesion  is  limited  to 
the  locality  mentioned,  adjacent  parts  may  become  secondarily  involved, 
and  these  small  round  cells  may  be  seen  in  the  meshes  of  the  tunica 
media  and  tunica  adventitia.  The  new  growth  gradually  becomes  organ- 
ized, and  is  supplied  with  nutrition  by  newly  formed  capillaries,  most 
clearly  seen  in  a  transverse  section. 

The  subsequent  morbid  process  is  a  subdivision  into  layers  of  the  new 
tissue  between  the  membrana  fenestrata  and  the  endothelium.  At  the 
same  time  a  new  membrana  fenestrata  is  formed  beneath  the  endothelium, 
which  is  regarded  by  Heubner,  not  as  an  essential  part  of  the  syphilitic 
process,  but  as  due  to  increased  activity  of  the  endothelium. 

In  the  early  stage  of  this  lesion,  very  slight  impediment  to  the  blood 
current  results,  but,  as  contraction  of  the  lumen  of  the  artery  goes  on, 
white  blood  corpuscles  are  deposited  along  its  inner  wall,  until  a  perfect 
thrombus  may  be  formed.  Occasionally  the  vessel  still  remains  slightly 
permeable. 

There  are  several  points  of  distinction  between  atheroma  and  this 
syphilitic  lesion.  The  latter  is  much  more  rapid  in  its  course,  and  usually 
occurs  much  earlier  in  life.  In  atheroma  the  calibre  of  the  vessel  is  seldom 
diminished,  while  in  syphilitic  endarteritis  complete  stenosis  may  result. 
Atheroma  generally  involves  more  extensive  surfaces  and  a  larger  number 
of  vessels  than  the  syphilitic  lesion,  and,  moreover,  in  the  latter,  there  is 
no  tendency  to  calcific  degeneration,  so  common  in  atheroma,  which, 
unlike  the  product  of  the  syphilitic  [)rocess,  is  incurable. 

It  is  the  opinion  of  Heubner,  with  which  we  and  other  observers,  par- 
ticularly the  English,  agree,  that  this  process  is  not  at  all  specific  in  its 
nature,  since  the  cells  are  similar  in  structure  and  arrangement  to  those 
of  certain  sarcomata  and  gliomata.  The  syphilitic  virus  seems  to  excite 
irritation  of  the  endothelium,  which  results  in  the  condition  previously 
described.  The  resemblance  of  this  lesion  to  gunimata  or  granulation 
tissue  is  very  marked.  We  have  observed  an  instance  in  which  it  existed 
in  the  left  Sylvian  artery,  continuous  with  a  gumma  completely  encircling 
that  vessel. 

Although  this  arterial  lesion  may  occur  as  early  as  the  first  year  of 
syphilis,  it  is  usually  developed  much  later,  having  generally  been  found 
associated  with  nodes  and  gummata  of  the  liver  and  testes.  As  a  rule,  it 
is  to  be  expected  at  about  the  third  year  of  syphilis,  but  may  occur  as 
late  as  the  twentieth.     (Heubner.) 

The  arteries  most  frecjuently  involved  are  the  large  vessels  at  the  base 
of  the  brain,  and,  for  reasons  already  given,  the  danger  to  an  extensive 
portion  of  the  cerebral  mass  from  defective  nutrition,  is  much  greater  than 
in  disease  of  arteries  distributed  to  the  convexity. 

The  changes  in  the  arterial  wall  may  be  so  slight,  that  unless  opened 
longitudinally,  the  vessel  shows  to  the  nuked  eye  no  evidence  of  abnor- 


648  AFFECTIONS    OF    THE    NERVOUS    SYSTEM. 

niality,  yet  there  may  have  been  sufficient  interfei-ence  with  the  circula- 
tion to  have  caused  decided  nervous  symptoms.  In  such  cases,  the  process 
being  limited  to  the  internal  layers  of  the  tunica  intima,  there  is  little 
rigidity  of  the  vessel  and  no  external  change,  hence  the  necessity  of 
careful  and  thorough  examination  of  all  the  vessels  of  the  brain.  Several 
cases  have  been  recorded,  in  which  the  symptoms  indicated  vascular 
lesions,  but  at  the  autopsy  nothing  abnormal  was  fouml,  although  proba- 
bly a  slight  sub-endothelial  change  was  overlooked. 

The  morbid  change  is  rarely  confined  to  a  segment  of  the  artery,  but 
usually  involves  its  entire  circumfex'ence,  and  generally  from  an  inch  to  an 
inch  and  a  half  of  its  continuity.  Several  vessels  may  be  involved  in 
different  stages  of  the  lesion,  or  only  one  may  be  affected. 

In  advanced  stages  of  the  morbid  process,  the  vessel  is  found  to  be 
thickened,  rigid,  and  slightly  compressible,  and  may  even  have  a  nodu- 
lated appearance,  due  to  excessive  cellular  development  and  invasion  of 
the  outer  tunics  at  certain  points.  A  thickened  artery  of  small  size  may 
present  sevei-al  rounded  expansions  within  the  limit  of  an  inch. 

Longitudinal  sections  of  an  artery  which  is  affected  to  an  extreme 
degree  shows  roughening  of  its  inner  surface,  which  has  lost  its  normal 
gloss  and  color,  being  dull  gray  where  the  lesion  is  recent,  and  brownish 
where  it  is  older. 

Thrombi,  with  or  without  distinct  laminte,  are  found,  some  very  thin 
and  friable,  others  firm  and  fully  occluding  the  vessel. 

Friedlander  and  Koster  believe  that  the  cellular  infiltration  of  the  tunica 
intima,  and,  in  proportion  to  the  intensity  of  the  process,  of  the  other 
coats  of  the  artery,  is  not  peculiar  to  syphilis,  but  is  found  in  inflamma- 
tory, tubercular,  carcinomatous,  and  other  growths.  They  compare  the 
process  to  that  of  organization  of  a  thrombus,  and  conclude  that  the  new 
cells  of  the  intima  are  derived  from  the  vasa  vasorum. 

While  Heubner  admits  that  the  cellular  infiltration  of  the  outer  coat  is 
derived  from  the  vasa  vasorum,  he  is  positive  in  his  opinion  that  the  cells 
found  in  the  inner  coat  are  furnished  by  proliferation  of  the  epithelial  lining 
of  the  vessel,  due  to  irritation  by  the  syphilitic  poison.  He  thinks  that  it 
is  a  gummatous  affection  beginning  in  the  intima,  independently  of  inflam- 
matory processes  without  tlie  vessel. 

Baumgarten  of  Konigsberg  has  studied  the  subject  carefully,  and 
though  agreeing  in  the  main  with  the  former  observers,  he  thinks  that 
Heubner  is  right  in  his  belief  that  the  infiltrating  cells  have  two  sources. 
The  growth  in  the  outer  coats  he  considers  gummatous  and  peculiar  to 
syphilis,  while  that  in  the  inner  coat  he  thinks  is  non-specific;  in  other 
words,  the  cells  from  the  vasa  vasorum  form  a  gumma,  while  those  derived 
from  the  endothelium  form  a  tissue  resembling  ordinary  granulation  tissue. 
In  the  thesis  of  Rabot,  another  variety  of  sy[)hilitic  arteritis  is  described, 
on  the  authority  of  M.  Charcot,  who  calls  it  "syphilitic  periarteritis,"  The 
details  are  given  of  an  autopsy  made  upon  a  syphilitic  woman,  thirty  years 
of  age,  at  which,  among  other  lesions,  was  found  upon  the  trunk  of  the  left 
Sylvian  artery,  near  its  origin,  a  nodosity  as  large  as  a  haricot  bean, 


AFFECTIONS    OF    THE    NERVES.  649 

whitish  in  color,  irregular  in  form,  and  appearing  to  involve  the  external 
tunics  of  the  vessel.  Similar  lesions  were  found  on  other  arteries,  but 
they  were  much  more  numerous  on  those  of  the  base  than  on  those  of  the 
convexity.  Microscopic  examination  of  these  tumors  showed  that  they 
were  the  result  of  an  acute  arteritis,  producing  thickening  of  the  internal 
coat,  with  infiltration  of  connective  tissue  cells  into  the  tunica  media. 
The  new  tissue  consisted  of  fusiform  cells  in  the  midst  of  a  finely  granular 
fibrillated  substance.  The  internal  elastic  tunic  was  intact,  while  the 
tunica  muscularis  was  infiltrated  with  round  embryonic  cells,  and  permeated 
by  capillaries.  Similar  young  cells  were  found  throughout  the  external 
coat,  chiefly  around  the  vasa  vasorum,  which  were  much  enlarged.  Con- 
traction of  their  walls  and  the  formation  of  thrombi  had  produced  occlu- 
sion of  the  vessels. 

Charcot  leans  to  the  opinion  that  this  is  a  true  syphilitic  periarteritis, 
but  refrains  from  a  positive  statement  until  he  has  made  further  observa- 
tions. 

We  have  seen  similar  changes  in  the  left  middle  cerebral  artery  coex- 
isting with  a  gummy  tumor. 

In  a  discussion  on  visceral  syphilis  at  the  Pathological  Society  of 
London,  Dr.  Gowers  showed  the  basilar,  middle,  and  posterior  cerebral 
arteries  of  a  syphilitic  man,  vvhicli  presented  several  nodules,  found  on 
microscopic  examination  to  consist  almost  entirely  of  small  round  and 
fusiform  cells  imbedded  in  a  delicate  fibrillated  stroma.  The  primary 
change  appeared  to  have  been  in  the  tunica  adventitia,  with  subsequent 
invasion  of  the  tunica  media.  The  suggestion  of  Charcot  is  sustained  by 
this  observation,  and  we  are  therefore  disposed  to  believe  in  the  existence 
of  a  syphilitic  periarteritis. 

An  acute  syphilitic  inflammation  of  the  arteries  has  been  described  by 
Dr.  Moxon.^  At  the  autopsy  of  a  syphilitic  man,  he  found,  among  other 
characteristic  lesions,  that  the  basilar  artery,  which  was  much  increased 
in  size  and  diminished  in  calibre,  presented  a  milky  appearance,  resem- 
bling boiled  macaroni.  The  walls  were  soft  and  had  the  appearance  of 
fresh  lymph.  The  microscope  showed  swelling  of  all  of  the  coats,  in  and 
between  which  were  numerous  closely  aggregated  corpuscles,  resembling 
pus  corpuscles.     The  lesion  was  abruptly  limited  and  had  a  smooth  surface. 

Affections  of  the  Nerves. 

The  cerebrospinal  nerves  may  be  involved  in  the  various  affections  of 
the  meninges;  they  may  be  encircled  by  gummy  tumors,  or  they  may  be 
compressed  by  swellings  at  the  bony  foramina.  The  resulting  symptoms 
are  anaesthesia,  hyperiEsthesia,  analgesia,  neuralgia,  paralysis,  or  disturb- 
ances of  the  special  senses. 

Syphilitic  lesions  being  most  frequent  in  the  neighborhood  of  the  inter- 
peduncular space,  the  nerves  near  this  region  arc  most  commonly  involved. 

»  London  Lancet,  Sept.  25,  1869. 


650  AFFECTIONS    OF    THE    NERVOUS    SYSTEM. 

The  third  pair  are  perhaps  most  often  affected,  the  first,  second,  fourth, 
and  sixth  quite  frequently,  while  syphilitic  changes  of  the  seventh  pair, 
or  facial  nerves,  are  rather  exceptional. 

The  syphilitic  lesions  of  the  optic  nerve  have  been  studied  by  Barbar,^ 
Arcoleo,"  and  Hulke,^  but  more  recently  by  Schott,*  who  describes  them 
very  accurately  and  illustrates  them  copiously  with  lithographic  plates. 
This  observer  confirms  the  view  of  Virchow,  that  there  may  be  both 
neuritis  and  perineuritis.  In  two  cases  he  found  free  proliferation  of 
young,  round,  nucleated  cells  in  the  connective-tissue  sheath,  with  some 
increase  of  the  spindle-shaped  cells.  He  found  similar  cells,  in  rows  and 
solitary,  in  the  nerve  tissue  itself  and  around  the  nutrient  vessels  of  the 
nerves.  The  nerve  bundles  were  separated  and  thinned  by  the  pressure. 
In  one  case  the  process  was  limited  to  a  portion  of  one  optic  nerve,  and 
was  more  pronounced  near  its  origin.  In  the  other  case,  though  both 
nerves  were  involved,  the  left  was  more  markedly  affected. 

Other  cranial  nerves  and  the  spinal  nerves  may  be  altered  in  a  similar 
manner,  with  or  without  coincident  lesions  of  adjacent  parts.  Heubner 
states  that  a  nerve  has  been  found  to  pass  through  a  syphilitic  new  growth 
and  yet  remain  normal. 

We  know  little  of  the  changes  caused  by  syphilis  in  the  peripheral 
nerves,  but  certain  clinical  facts  indicate  that  they  may  be  affected  in  a 
similar  way.  A  number  of  writers  describe  the  gross  appearances  as  fol- 
lows :  in  the  early  stage  they  lose  their  rounded  shape  and  become  swollen ; 
they  assume  a  reddish-yellow  color  and  a  soft  and  pulpy  consistency;  at 
the  same  time,  the  swelling  may  give  them  a  bulbous  appearance;  subse- 
quently, they  become  atrophied  into  yellowish-white,  cartilaginous  cords. 
This,  like  all  other  syphilitic  lesions,  is  limited  to  certain  portions,  and 
never  attacks  the  entire  length  of  a  nerve.  We  are  wholly  ignorant  of 
any  primary  change  in  the  nerve  fibres  and  axis-cylinder. 

The  sympathetic  nerves  may  undergo  two  varieties  of  change :  one 
affecting  the  nerve  cells  and  characterized  by  piginentaiy  and  colloid 
degeneration  ;  the  other  consisting  of  a  connective-tissue  proliferation. 
Tliese  conditions  were  found  by  Dr.  Petron,  on  microscopic  examination 
both  of  fresh  specimens  and  of  those  hardened  in  chromic  acid,  in  the 
cervical,  thoracic,  and  solar  plexuses  of  syphilitic  subjects.  He  draws  the 
following  conclusions  from  his  studies  : — * 

1.  The  syphilitic  diathesis  affects  the  sympathetic  nerve,  determining 
very  distinct  alterations. 

2.  The  nerve  cells  may  undergo  change  independently  of  the  connec- 

•  Ueber  einige  seltenere  syph.  Erkrankungen  des  Auges,  Zurich,  Inaug.  dissert., 
1873. 

2  Clin,  ottal.  di  Palermo,  1871.     Quoted  by  Schott. 
8  Ophth.  Hosp.  Rep.,  London,  1869. 

*  On  some  Aifections  of  the  Optic  Nerve,  Arch,  of  Ophth.  and  Otol.,  N.  Y.,  1877, 
vol.  vi,  Nos.  1,  2. 

5  Arch.  f.  path.  Anat.,  etc.,  Berlin,  1873,  S.  121. 


PRODROMAL    SYMPTOMS.  651 

tive  tissue,  consisting  of  pigmentary,  and,  less  frequently,  of  colloid  degene- 
ration. 

3.  The  connective  tissue  may  undergo,  as  elsewhere,  sclerosis,  and  cause 
atrophy  of  the  nervous  elements. 

4.  The  membrane  covering  the  nerve  cells  may  be  involved,  at  first  by 
liypertrophy  from  cell-infiltration,  which  may  afterwards  undergo  fatty 
degeneration. 

Cerebral  Syphilis  sine  Materia. 

There  are  certain  groups  of  symptoms  observed  in  syphilitic  subjects, 
which  can  be  explained  only  by  admitting  the  possibility,  now  generally 
recognized,  of  a  temporary  condition,  possibly  hypenemic,  of  the  nervous 
system,  caused  by  the  syphilitic  virus. 

The  term  Cerebral  Syphilis  sine  Materia  has  been  given  by  some  pi'omi- 
nent  authors  to  syphilitic  nervous  affections,  w^hich  present  no  perceptible 
nervous  lesion.  The  view  that  these  affections  may  exist  without  struc- 
tural change,  is  based  on  the  autopsies  of  several  cases,  in  which  severe 
nervous  symptoms  had  been  present,  yet  nothing  abnormal  was  found. 
Some,  who  hold  this  view,  think  that  the  morbid  change  may  have  been 
so  occult  and  delicate  as  to  have  eluded  discovery  by  the  methods  of  inves- 
tigation then  known. 

Our  present  knowledge  of  the  lesions,  which  may  cause  syphilitic  ner- 
vous affections,  is  much  more  extensive  and  precise.  There  is  reason, 
therefore,  for  the  suspicion  that  changes  actually  did  exist  in  the  cases  re- 
ferred to,  which  were  overlooked  ;  possibly  minute  tumors,  which  easily 
escape  notice,  or  structui-al  changes  in  the  walls  of  the  cerebral  arteries, 
which  may  be  invisible  except  on  longitudinal  section  of  the  vessels. 

We  cannot  deny  that  cerebral  syphilis  sine  materia  may  exist,  but  be- 
fore accepting  it  as  the  diagnosis  in  a  given  case,  it  must  be  i)roved  that 
the  autopsy  was  carefully  and  thoroughly  made. 

Prodromal  Symptoms. 

The  sudden  invasion  of  cerebral  syphilis  is  unusual.  In  most  cases 
there  is  a  well-marked  prodromal  stage,  in  which  one  or  more  of  the  fol- 
lowing symptoms  may  be  presented. 

One  of  the  most  frequent,  and  often  the  only  symptom  of  tliis  stage  is 
headache,  which  is  usually  general  but  may  be  limited  to  the  occipital  and 
frontal  regions.  It  may  be  very  slight,  or  so  excruciating  that  patients 
say  they  feel  as  though  tlie  head  were  in  a  vice.  In  mild  cases  the  pain 
ceases  at  night,  but  in  others  sleep  is  entirely  prevented.  It  may  disap- 
pear without  treatment  in  a  week  or  ten  days,  but  has  been  observed  to 
continue  fully  two  months.  Its  duration  is  wonderfully  influenced  by 
mercury,  even  though  it  may  resist  the  most  powerful  narcotics.  Several 
recurrences  of  this  form  of  headache  may  take  place  within  the  first  year 
or  two  of  syphilis.     Neuralgia  of  one  or  more  of  the  cranial  nerves  may 


652  AFFECTIONS    OF    THE    NERVOUS    SYSTEM. 

accompany  it,  especially  in  those  subject  to  this  affection.  The  fact  that 
this  form  of  headache  occurs  when  the  blood  is  most  profoundly  modified 
by  syphilis  indicates  that  it  is  due  to  changes  in  that  fluid. 

A  vai'iety  of  headache  which  sometimes  comes  on  early  in  the  secondary 
stage  exhibits  an  important  diagnostic  feature  in  nocturnal  exacerbation. 
It  may  exist  during  the  day  with  abated  severity  or  may  be  wholly  absent, 
and  begin  at  some  time  during  the  evening  or  night.  It  is  usually  con- 
fined to  a  single  I'egion,  and  frequently  small  patches  of  syi)hilitic  lesions 
of  the  bones  or  of  the  meninges  may  be  defined  by  pressure  with  the  tip 
of  the  finger,  which  intensifies  the  pain.  It  is  always  symptomatic  of 
grave  structural  change,  and  is  likely  to  vary  in  intensity  with  the  serious- 
ness of  the  lesion.  Its  course  is  always  chronic.  Sometimes  it  is  dis- 
tinctly intermittent,  or  it  may  cease  spontaneously  for  i\iiys  or  weeks,  then 
return  and  continue  for  weeks  or  even  months.  Usually  it  does  not  cease 
with  the  onset  of  the  profound  symptoms  of  which  it  is  a  premonition,  but 
persists  throughout.  A  headache  with  somewhat  similar  features  may  ac- 
company the  development  of  nodes  on  the  exterior  of  the  cranium. 

In  exceptional  cases,  sleeplessness  is  a  troublesome  and  persistent  pro- 
dromal symptom,  and  exists  without  any  disturbance  of  the  general  health, 
or  towards  night  there  may  be  a  feeling  of  uneasiness  and  nervousness. 
Sometimes  this  feeling  persists  through  the  day.  Such  patients  are  indis- 
])Osed  to  active  exercise,  and  become  excessively  tired  on  slight  exertion. 
They  may  seem  to  be  otherwise  in  good  health  and  well  noui-ished,  or 
cachexia  may  set  in,  with  emaciation  and  that  earthy  pallor  peculiar  to 
syphilis.  This  cachectic  state  is  probably  present  in  one-half  of  the  cases 
of  cerebral  syphilis,  especially  those  in  which  the  nervous  symptoms  appear 
late  in  the  course  of  the  disease. 

Vertigo  is  a  prominent  prodromal  symptom,  and  a  constant  accompani- 
ment of  that  headache  which  lasts  through  the  day.  It  may  be  a  tempo- 
rary dizziness,  or  so  extreme  that  the  patient  feels  at  times  as  though  he 
were  losing  his  senses. 

There  may  be  a  varying  degree  of  mental  confusion  or  weakness.  Slight 
impairment  of  the  memory,  slow,  and  perhaps  incoherent  mental  action 
may  be  exhibited,  while  the  speech  may  be  hesitating,  not  from  difficulty 
of  plionation,  but  from  impaired  intellection.  Such  patients  may  become 
petulant,  melancholy,  and  morbidly  emotional.  They  frequently  complain 
of  nervousness  and  a  tendency  to  become  frightened  and  to  tremble  on  the 
slightest  cause.  Numbness  in  the  head,  darting  pains,  hypertesthesia  or 
anaesthesia,  with  weakness  of  the  extremities,  may  be  experienced.  Some- 
times choreic  movements  are  marked.  Photophobia,  intermittent  or  con- 
tinuous, and  often  coexisting  with  dull  fi'ontal  headache,  has  been  noticed 
in  some  cases.  There  may  also  be  mild  ataxic  symptoms  in  the  prodromal 
stage,  and  not  infrequently  paralysis  of  one  or  more  of  the  cranial  nerves, 
especially  those  distributed  to  the  muscles  of  the  eye. 

Finally,  nocturnal  delirium,  mild  or  maniacal,  is,  in  some  cases,  a  very 
prominent  symptom.  This  condition  leaves  the  patient  in  the  morning 
depressed  and  uninvigorated,  with  a  dull,  heavy  sensation  in  the  head. 


SYPHILITIC    TUMORS    OF    THE    NERVOUS    SYSTEM.  053 

Some  or  all  of  the  preceding  symptoms  may  exist  for  variable  periods, 
and  on  the  outbreak  of  grave  manifestations,  they  undergo  modifications  to 
be  hereafter  described. 


Syphilitic  Tumors  of  the  Nervous  System. 

Two  forms  of  syphiloma,  or  syphilitic  tumor,  are  found  in  the  cranio- 
vertebral  cavity,  which  differ  widely  in  gross  appearances,  but  are  com- 
posed of  similar  structui-al  elements.  These  tumors  are  usually  connected 
with  the  cerebrum ;  they  have  rarely  been  found  in  the  medulla  oblongata 
or  in  the  cord,  and  we  are  not  aware  of  any  having  been  observed  either 
upon  or  within  the  cerebellum. 

The  first  form  is  of  a  grayish-red  color  and  is  extremely  vascular,  most 
of  the  vessels  being  veiy  minute,  while  some  are  plainly  visible  to  the 
naked  eye.  When  developed  exclusively  in  the  pia  mater  and  arachnoid, 
the  tumor  is  soft  and  slightly  fibrous;  but,  if  it  is  formed  only  in  the  dura 
mater,  its  consistence  is  quite  firm,  owing  to  the  abundance  of  fibrous 
tissue. 

Under  high  powers  of  the  mici'oscope  the  tumor  is  found  to  consist  of 
small  round  cells,  arranged  regularly  or  without  order  in  a  very  delicate 
alveolar  stroma  of  connective  tissue.  The  walls  of  the  newly  foi'med 
vessels  are  usually  much  thickened  by  cell  increase. 

The  second  form  of  tumor,  which  is  harder  and  of  a  yellowish  color,,  is 
merely  a  late  and  degenerating  stage  of  the  first  variety.  Excess  of  fibrous 
tissue  renders  its  structure  more  dense  and  its  boundaries  more  clearly 
defined.  The  bloodvessels  are  few,  and,  while  permeable  at  the  periphery, 
at  the  centre  of  the  tumor  they  are  converted  into  fibrous  cords.  On 
section,  the  tumor  is  slightly  resistant  to  the  knife,  and  appears  more  or 
less  desiccated.  Microscopic  examination  shows  a  distinctly  fibrous  stroma, 
in  which  is  imbedded  a  large  quantity  of  withered  cells,  granular  and  fatty 
matter,  and  blood  crystals. 

These  tumors  vary  greatly  in  number  and  in  size ;  there  may  be  a  single 
one  or  the  surface  of  the  hemisphere  may  be  studded  with  large  numbers 
of  them,  resembling  the  condition  in  miliary  tuberculosis  ;  they  may  be  of 
tiie  size  of  a  pea  or  of  a  small  walnut.  They  are  usually  round  or  oval, 
but  in  some  situations  they  become  flattened.  They  have  been  found 
encircling  an  artery,  and  it  is  probable  that  their  origin  is  always  around 
some  vessel,  particularly  one  traversing  the  large  fissures  of  the  brain. 
In  rare  instances  the  soft  form  of  tumor  has  been  found  in  large  patches, 
involving  chiefly  the  vascular  cerebral  membranes,  and  having  a  thickness 
of  from  one-quarter  to  one-half  an  inch,  and  constituting  in  reality  a  gum- 
mous  meningitis. 

These  tumors  are  found  chiefly  on  the  inferior  surface  of  the  brain,  in 
the  region  of  the  fissure  of  Sylvius.  Great  care  must  be  employed  in 
examining  the  hemispheres,  since  such  growths  may  exist  in  any  recess 
of  the  brain,  into  which  the  vascular  membranes  are  reflected.     Heubner 


6o4  AFFECTIONS    OF    THE    NERVOUS    SYSTEM. 

says  that  frequently,  after  having,  as  he  supposed,  finished  an  autopsy,  he 
has  run  across  minute  tumors  hidden  in  such  situations. 

The  facts  thus  far  recorded  warrant  the  opinion  that  tliese  tumors  are 
always  periplieral,  and,  if  found  imbedded  in  the  brain  tissue,  they  have 
grown  inwards  from  the  vascular  membranes. 

Meningeal  Symptoms. 

There  is  a  group  of  symptoms  of  constant  occurrence,  especially  in  the 
early  years  of  syphilis,  which  are  distinctly  referrible  to  inflammation  of 
the  meninges. 

The  first  of  the  group  is  the  headache  already  referred  to.  This  symp- 
tom continues  for  a  variable  period,  during  which  the  general  health  is 
gradually  but  evidently  becoming  impaired.  The  patient  complains  of 
feeling  weak ;  he  is  fatigued  on  slight  exertion  and  is  indisposed  to  physi- 
cal or  mental  effort.  Emaciation  may  be  a  marked  symptom  in  some 
cases,  while  in  othei's  there  is  a  tendency  to  fatty  development  with  a 
consequent  flabby  appearance.  Not  infrequently  there  is  true  syphilitic 
cachexia,  with  its  typical  facies.  Coincidently  with  these  general  disturb- 
ances of  nutrition,  we  find  prominent  symptoms  of  mental  impairment. 
Thus,  a  patient  affected  in  this  manner  expi-esses  himself  vaguely  in  con- 
versation, is  slow  and  uncertain  in  his  utterance  or  even  incoherent.  Plis 
statements  are  confused  and  rambling;  his  replies  hesitating,  more  or  less 
inexact,  and  perhaps  inappropriate.  In  short  there  is  general  dulness  and 
torpor  of  the  intellect. 

In  other  cases  we  find  the  patient  with  a  dull,  vacant  stare  upon  his 
face.  If  asked  what  he  is  thinking  of,  he  gives  no  intelligent  answer. 
His  memory,  his  reasoning  and  his  perceptive  faculties  are  sadly  at  fault. 
In  health  he  may  have  been  vivacious  and  quick  of  comprehension  :  he  is  now 
dull,  stupid,  and  morose;  his  ordinary  habits,  tastes,  and  inclinations  are 
changed  and  debased.  He  is  fault-finding,  suspicious,  and  quarrelsome, 
often  very  emotional,  laughing  or  crying  on  the  slightest  provocation ;  or, 
again,  he  may  present  the  silly,  stupid  appearance  of  complete  hebetude. 
A  case  of  this  kind,  if  not  checked  by  treatment,  is  likely  to  terminate  in 
confirmed  dementia. 

Again,  the  above  series  of  symptoms  may  be  varied.  Hemiplegia, 
aphasia,  or  convulsions  may  appear  at  either  an  early  or  a  late  period.  In 
very  many  instances  paralysis  of  one  or  more  cranial  nerves  supervenes  at 
an  early  date,  and  mydriasis,  either  with  or  vpithout  ptosis  of  one  or  both 
lids,  has  been  so  frequently  noted  that  its  occurrence  should  always  excite 
suspicion.  Other  ocular  disturbances,  such  as  progressive  atrophy  of  the 
optic  nerve,  paralysis  of  the  muscles  of  the  eyeball,  serous  iritis  of  one  or 
both  eyes,  with  its  accompanying  photophobia,  are  not  uncommon,  and 
have  been  more  fully  described  in  a  previous  chapter. 

We  have  noticed,  and  several  authors  also  allude  to  it,  a  peculiar  and 
persistent  hypertemia  of  the  eye  and  lids,  similar  to  that  which  accom- 
panies iritis.     This  condition  may  become  chronic,  and  it  has  often  been 


MENINGEAL    SYMPTOMS.  655 

found  to  be  intermittent,  becoming  most  marked  during  exacerbation  of 
the  nervous  symptoms.  8uch  patients  com[)lain  of  photophobia,  which  is 
sometimes  so  intense  that  they  are  completely  dazed  by  any  sudden  or 
strong  ray  of  light.  These  symptoms  are  undoubtedly  dependent  upon  a 
low  stage  of  choroiditis. 

Other  special  senses  may  also,  though  less  frequently,  be  impaired. 
That  of  smell  is  sometimes  diminished,  or,  at  an  advanced  stage,  wholly 
lost;  or  it  may  be  much  perverted,  so  that  unpleasant  odors  are  constantly 
complained  of.  The  hearing  may  be  impaired  or  destroyed.  Noisco  of 
various  kinds  (tinnitus  aurium)  are  experienced;  while  otalgia,  generally 
nocturnal,  is  an  occasional  symptom. 

A  general  adynamic  condition  sometimes  supervenes  in  patients  affected 
with  chronic  inflammation  of  the  meninges,  which  either  ends  fatally  or 
renders  them  hopelessly  bedridden.  This  weakness  may  be  due  to  mere 
lack  of  innervation,  or  may  be  complicated  by  mild  ataxic  phenomena, 
characterized  by  unsteady  gait  and  uncertain  movements.  The  dulness 
of  intellect  by  day  is  succeeded  by  nocturnal  delirium.  When  lying  in 
bed  such  a  patient  resembles  one  in  typhoid  fever,  but  there  are  marked 
points  of  difference.  He  is  sleepy  and  dull,  and  his  face  is  utterly  expres- 
sionless. The  tip  and  edges  of  his  tongue  are  red,  but  the  organ  is  never, 
unless  late  in  fatal  cases,  dry,  cracked  and  covered  with  sordes. 

Anorexia  and  constipation  are  often  quite  marked. 

The  pulse  ranges  from  80  to  110,  is  full  and  not  wiry.  The  tempera- 
ture may  be  elevated  in  the  morning  to  1U0°  F.,  and  at  night  to  103° 
or  104^  F. 

If  conscious,  tlie  patient  complains  of  intense  headache  and  weariness. 
In  a  week  or  ten  days  he  passes  into  a  condition  of  complete  unconscious- 
ness, perhaps  broken  by  brief  lucid  intervals. 

The  urine  and  feces  are  passed  involuntarily.  If  not  relieved,  the  con- 
dition soon  becomes  more  serious ;  the  temperature  continues  to  rise,  and 
the  pulse  increases  in  rapidity  :  no  food  is  taken,  and  the  stupor  merges 
into  fatal  coma. 

The  above  course  of  events  has  been  ol)served  in  a  number  of  instances 
of  quite  recent  syphilitic  infection,  varying  between  the  second  and  sixth 
years  ;  it  may  occur  even  as  early  as  the  Hrst  year. 

Thus  it  is  seen  that  inflammation  of  the  meninges  has  a  distinct  group 
of  symptoms  by  which  it  may  be  recognized,  and  that  it  may  be  compli- 
cated by  other,  and  perhai)s  more  formidable  symptoms.  In  the  simple 
inflammation,  the  lesion  is  i)robably  limited  to  the  convexity  of  one  of  the 
hemispheres ;  when  the  opposite  side  of  the  brain  is  involved,  or  when  the 
basal  portion,  where  the  cranial  nerves  have  their  origin,  is  attacked,  the 
case  becomes  complicated  by  a  series  of  new  features,  such  as  paralyses, 
and  other  impairments  of  nervous  function. 

This  view,  which  is  supported  by  the  clinical  history  of  cerebral  hyper- 
emia, and  simple  meningitis,  and  Ijy  our  knowledge  of  the  course  and 
pathology  of  syphilis,  seems  to  simplify  a  large  number  of  apparently  ob- 
scure cases.     The  various  phenomena,  such  as  paralyses,  epilepsy,  aphasia, 


G5G  AFFECTIONS    OF    THE    NERVOUS    SYSTEM. 

etc.,  which  may  arise  from  similar  causes  in  both  the  chronic  and  the  more 
acute  form  of  syphilitic  meningitis,  will  receive  separate  attention  here- 
after. 

The  time  of  the  invasion  of  meningitis  is  uncertain  :  the  acute  form  is 
generally  observed  in  the  early  years  of  syphilis.  It  is  only  the  adynamic 
form  which  is  liable  to  be  mistaken  for  typhoid  fever.  A  correct  diagnosis 
may  be  reached  from  the  history  of  the  case,  from  the  severity  and  early 
supervention  of  the  head  symptoms,  and  from  the  absence  of  the  character- 
istic typhoid  tongue  and  of  signs  indicating  intestinal  lesions.  In  certain 
cases  of  sunstroke,  which  may  present  features  of  striking  resemblance,  the 
acuteness  of  the  invasion  and  the  totally  different  character  of  the  head- 
ache, in  addition  to  the  previous  history  of  the  patients,  may  enable  us  to 
avoid  error. 

Syphilophobia. 

Syphilophohia  is  sometimes  included  among  the  manifestations  of  syphilis, 
but  we  do  not  believe  that  it  is  directly  due  to  this  disease.  It  is  quite  as 
often  met  with  in  patients  affected  only  with  gleet,  prostatorrhoea,  or  who 
have  nothing  in  the  world  the  matter  with  them,  except  their  own  disor- 
dered imagination.  Moreover,  in  truly  syphilitic  cases,  the  fear  of  syphilis 
often  increases  in  proportion  as  the  specific  symptoms  disappear.  A  few 
years  ago,  I  had  under  my  charge  a  member  of  Congress  affected  with 
syphilis,  who  imagined,  while  his  eruption  was  fading,  that  he  was  "rot- 
ting internally."  So  long  as  I  was  willing  to  continue  treatment,  he  was 
somewhat  pacified,  but  one  day  when  every  trace  of  his  affection  had  long 
since  passed  away  and  I  told  him  that  he  needed  no  more  medicine,  he 
went  to  his  room  and  shot  himself  dead  with  a  pistol. 

Syphilitic  patients  will  sometimes  state  that  they  have  resolved  to  give 
up  their  business  and  devote  their  time  to  the  cure  of  their  disease.  Such 
a  course  should  always  be  discouraged,  since  it  favors  mental  depression, 
interferes  with  the  general  health,  and  thus  retards  the  effect  of  remedies, 
and  may  lead  to  confirmed  hypochondria  or  syphilophobia. 

Hemiplegia. 

One  of  the  most  frequent  phenomena  of  cerebral  syphilis  is  hemiplegia, 
which  may  occur  as  early  as  the  sixth  month  or  as  late  as  twenty  years 
after  infection.  The  interference  with  the  motor  function  may  be  slight 
or  there  may  be  complete  loss  of  power.  It  is  generally  preceded  by  a 
stage,  in  which  a  jirominent  symptom  is  localized  headache,  often  asso- 
ciated with  many  of  the  other  symptoms  already  mentioned,  such  as  mental 
disturbance,  hebetude,  vertigo,  and  convulsions  which  are  often  immedi- 
ately followed  by  the  paralytic  stroke. 

In  some  cases  muscular  spasm,  a  form  of  pre-paralytic  chorea,  has  been 
observed  in  the  limbs  afterwards  paralyzed.  For  instance,  the  arm  may 
be  jerked  in  various  directions,  or  the  patient  may  find  it  impossible  to 


HEMIPLEGIA.  657 

place  the  foot  firmly  on  the  ground,  the  leg  being  pulled  suddenly  from 
under  him,  when  he  attempts  to  stand. 

In  other  cases  darting  pains  are  felt  in  the  leg  or  ai-m,  or  constant 
neuralgic  pain  may  exist  in  some  part  of  the  limb ;  or  there  may  be  numb- 
ness or  tingling  in  the  hands  and  feet  with  patches  of  hyperaesthesia  or 
ana?stliesia. 

In  cases  of  gradual  invasion  total  paralysis  seldom  occurs.  The  patient 
first  notices  that  he  is  losing  strength,  perhaps  in  his  fingers,  so  that  he 
finds  himself  unable  to  button  bis  clothing  or  to  hold  a  pen  firmly.  This 
condition  may  continue  until  paralysis  comes  on,  or  it  may  be  intermittent, 
the  normal  strength  returning  at  intervals.  When  the  leg  is  thus  affected 
the  patient  naturally  has  more  or  less  difficulty  in  walking.  Complete 
hemiplegia  has  been  seen  to  come  on  in  this  gradual  manner,  but  is  gener- 
ally sudden.  Sometimes  the  leg  is  affected  several  hours  before  power  is 
lost  in  the  arm.  The  reverse,  however,  is  infrequent.  Patients  are  usually 
attacked  with  hemiplegia,  when  engaged  in  some  act  of  muscular  cflTort, 
such  as  pulling  on  the  boots,  walking  briskly,  reaching  for  some  object,  or 
on  the  point  of  shooting  at  game  (Van  Buren  and  Keyes).  On  the  con- 
trary, the  attack  may  happen  during  the  night,  and  the  patient  be  unable 
to  rise  from  bed  in  the  morning. 

The  course  and  duration  of  hemiplegia  vary  greatly.  When  partial, 
the  paralysis  may  gradually  improve,  and  even  disappear  spontaneously  in 
a  few  days;  or,  as  improvement  takes  place,  the  opposite  side  may  be 
similarly  affected,  followed  by  recurrence  of  the  paralysis  on  the  side  first 
involved.  These  cases  are  accompanied  by  excessive  mental  impairment, 
and,  as  a  rule,  have  an  early  fatal  termination.  Syphilitic  hemi[)legia  is 
caused  by  lesions  of  the  arteries,  and,  in  cases  of  the  latter  class  just 
mentioned,  the  vessels  of  each  side  of  the  brain  are  implicated. 

Disturbance  of  general  sensation  is  usually  limited,  but  instances  of  slight 
loss  of  motor  power  with  complete  loss  of  the  sensory  function  have  been 
reported.  In  exceptional  cases  there  may  be  total  loss  of  both  motion  and 
sensation. 

A  great  variety  of  phenomena,  depending  upon  the  extent  and  situation 
of  the  lesions,  may  accompany  syphilitic  hemiplegia;  such  as  paralysis  of 
various  nerves;  aphasia,  mydriasis,  optic  neuritis,  and  epilepsy.  Mental 
depression  seems  to  be  constant,  and  most  patients  either  display  a  condi- 
tion of  complete  hebetude  or  are  excessively  emotional. 

Early  and  energetic  treatment  may  accomplish  the  relief  and  even  the 
cure  of  hemiplegia,  but  the  prognosis  is  greatly  influenced  by  the  age  and 
extent  of  the  lesion.  The  arteries  arising  from  the  circle  of  Willis  sup- 
ply the  most  important  regions  of  the  brain,  and  are  most  fre(piently 
affected  by  syphilis  ;  obviously,  if  but  one  is  involved,  the  prognosis  may 
be  more  favorable  than  if  many  are.  The  number  and  gravity  of  the 
symptoms  Avill  usually  give  an  idea  of  the  extent  of  the  lesion.  In  a 
simple  case  of  hemiplegia,  probably  only  one  or  two  vessels  are  affected, 
and  complete  recovery  may  take  place,  but  when  other  syni[)toms,  indica- 
tive of  extensive  disorganization  of  the  brain  are  exhibited,  tiie  prognosis 
42 


058  AFFECTIONS    OF    THE    NERVOUS    SYSTEM. 

must  be  less  favorable.  As  a  rule,  perfect  health  is  in  no  case  restored, 
althougli  the  patient  may  present  no  conspicuous  abnormality.  We  may 
say,  however,  that  the  prognosis  in  syphilitic  liemiplegia  is  better  than  in 
the  simple  form. 

Syphilitic  hemiplegia  usually  occurs  much  earlier  in  life  than  the  simple 
variety,  which  is  not  commonly  seen  before  the  age  of  forty  years.  In 
diao"nosis,  therefore,  it  should  be  remembered  that  syphilis  is  the  cause  of 
most  of  the  cases  of  hemiplegia  in  the  young  and  middle-aged.  The  fact 
that  a  patient  rarely  loses  consciousness  wdien  attacked  by  syphilitic  hemi- 
plegia, is  an  additional  diagnostic  point  of  importance. 

Syphilitic  Epilepsy. 

This  is  of  frequent  occurrence  in  cerebral  syphilis,  and,  like  non-spe- 
cific epilepsy,  presents  two  forms,  the  grand  mal  and  the  petit  mal.  Head- 
ache, increasing  in  severity,  always  precedes  an  attack.  The  symptoms  of 
the  severe  form  are  similar  to  those  of  the  non-specific  variety,  consisting 
of  sudden  loss  of  consciousness,  tonic  followed  by  clonic  spasms,  facial 
distortion,  foaming  at  the  mouth  and  stertorous  respiration.  According 
to  some  authors  the  epileptic  aura  and  cry  are  absent.  Such  convulsions 
generally  recur  at  short  intervals,  and  frequently,  with  distinct  regularity, 
every  ten  days  or  once  a  month.  Instances  of  their  regular  occurrence  in 
the  evening  and  at  night  have  been  reported,  but,  as  a  rule,  they  come 
on  at  no  definite  time.  In  some  cases  consciousness  returns  in  a  few 
minutes,  in  others  the  patient  remains  in  a  stupid  condition  for  hours,  and 
may  not  be  fully  restored  for  several  days.  After  the  seizure  the  head- 
ache may  be  much  less  severe  for  a  time,  but,  unless  treatment  is  followed, 
its  intensity  soon  returns. 

The  course  of  syphilitic  epilepsy  is  uncertain,  and  may  be  greatly 
modified  by  treatment.  When  convulsions  follow  a  long  prodromal  stage, 
in  which  symptoms  of  mental  disturbance  have  been  particularly  severe, 
the  prognosis  must  be  rather  unfavorable ;  cases  in  which  they  follow  a 
short  period  of  headache,  generally  yield  to  proper  treatment,  as  we  have 
several  times  observed.  Tonic  spasms  may  precede  or  follow  an  attack  of 
hemiplegia,  and  are  often  seen  in  connection  with  permanent  or  inter- 
mittent aphasia.  They  are  generally  caused  by  pachymeningitis,  though 
probably,  in  some  cases,  as  claimed  by  Jackson,  irritation  from  a  tumor  is 
the  exciting  cause. 

The  intervals  of  syphilitic  epilepsy,  unlike  those  of  apparent  health  in 
the  simple  form,  are  marked  by  symptoms  of  mental  disturbance,  which 
tends  to  increase,  and  may  finally  end  in  dementia. 

The  mild  form,  called  by  Charcot  partial  syphilitic  epilepsy,  may  exist 
independently,  or  combined  with  the  severe  form.  The  paroxysm  may 
begin  either  with  a  twitching  of  one  side  of  the  face,  a  turning  of  the 
tongue  to  one  side,  a  tendency  on  the  part  of  the  patient  to  whirl  around, 
extreme  giddiness,  general  trembling,  or  great  weakness  or  cramps  of  the 
extremities,  which  are  followed  by  loss  of  consciousness  and  a  convulsion, 


SYPHILITIC    PARAPLEGIA.  659 

consisting  either  of  slight  muscular  tremor  or  of  general  tonic  spasm. 
The  seizure  may  be  limited  to  a  single  limb  or  to  one  side  of  the  body, 
and  in  some  cases  amounts  to  nothiijg  more  than  slight  rigidity.  The 
severity  and  length  of  the  attack  are  much  less  than  in  the  grand  mal. 

Frequently  there  is  no  convulsion  at  all,  but  the  patient,  while  talking  or 
in  performing  any  act,  becomes  unconscious,  and  is  seen  to  stare  vacantly. 
If  sitting,  he  becomes  motionless  ;  if  walking,  he  does  not  fall,  but  pro- 
ceeds in  an  uncertain  aimless  manner,  and,  if  in  the  midst  of  conversation, 
he  suddenly  becomes  obtuse  and  fails  to  comprehend  any  question  ad- 
dressed to  him.  "While  in  this  condition,  which  may  last  only  a  few 
seconds  or  even  twenty  minutes,  he  may  perform  rational  acts,  such  as 
paying  properly  for  a  purchased  article,  or  he  may  even  walk  along  with- 
out staggering,  and  when  his  senses  are  restored,  he  may  recall  indistinctly 
or  not  at  all  what  he  has  said  or  done. 

Dr.  Hughlings  Jackson  has  described  a  form  of  seizure  which  he  has 
found  to  be  caused  by  syphilis,  and  to  be  accompanied  or  followed  by 
optic  neuritis.  It  begins  unilaterally  as  a  mere  twitch,  a  slight  rigidity, 
or  a  violent  convulsion,  in  most  cases  in  the  thumb  and  forefinger.  It 
may  be  limited  to  the  arm,  along  which  it  extends,  or  it  may  also  involve 
the  face  of  the  same  side  ;  it  may  reach  the  leg,  and  constitute  a  hemispasm 
or  finally  it  may  proceed  to  general  convulsion.  During  the  intervals, 
which  vary  in  length,  a  course  of  symptoms,  similar  to  those  of  the  grand 
mal,  though  perhaps  of  milder  cliaracter,  may  be  observed. 

The  diagnostic  points  of  syphilitic  epilepsy  are  : 

1.  The  history  of  the  patient. 

2.  The  paroxysmal  headache. 

3.  The  frequency  of  mental  disturbance. 

4.  The  frequent  coexistence  of  optic  neuritis,  hemiplegia,  aphasia,  and 
paralyses  of  various  nerves. 

.5.  The  age  of  the  patient. 

6.  The  result  of  treatment. 

Simple  epilepsy  is  usually  developed  before  puberty,  whereas  that  caused 
by  syphilis  generally  occurs  between  the  ages  of  twenty  and  thirty,  the  period 
when  syphilis  is  most  frequently  contracted.  The  former  is  either  uninflu- 
enced or  aggravated  by  the  iodide  of  potassium  and  mercurials,  whereas 
their  influence  on  the  latter  is  favorable,  and,  in  some  cases,  curative. 

Stpiiilitic  Paraplegia. 

Though  the  spinal  cord  is  attacked  by  syphilis  less  frequently  than  the 
brain,  at  least  one-half  the  cases  of  paraplegia  are  of  syphilitic  origin. 

Tlic  symptoms  are  not  strongly  marked.  The  patient,  who  may  or  may 
not  suffer  from  pain  in  the  back,  notices  slight  weakness  of  the  lower  ex- 
treoiities,  and  may  also  comi)lain  of  one  or  more  of  the  following  symp- 
toms :  darting  pains  and  s[)asms  in  the  legs,  numbness,  tickling,  or  aching 
pains  in  the  feet,  hyperajsthesia,  anicsthesia,  derniatalgia,  and  formication. 
Loss  of  co-ordinating  power  may  be  observed.     There  is  usually  progres- 


660  AFFECTIONS    OF    THE    NERVOUS    SYSTEM. 

sive  weakness  in  the  expulsive  power  of  the  rectum  and  bladder.  This 
condition  may  remain  stationary  for  a  long  time,  or  it  may  improve  tem- 
porarily, but,  unless  treatment  is  adopted,  complete  paralysis  of  both  legs 
finally  ensues.  On  the  other  hand  the  development  of  paraplegia  may  be 
much  more  rapid. 

General  sensation  may  be  preserved,  slightly  impaired  or  wholly  lost. 
Exceptionally  it  is  destroyed  while  the  motor  function  remains  perfect. 
After  the  establishment  of  full  paralysis,  there  may  be  short  intervals  of 
sli«yhtly  restored  power  or  there  may  be  jerking  of  the  muscles. 

Paraplegia  may  be  the  only  manifestation  of  syphilis  existing  at  this 
time,  but  frequently  there  are  evidences  of  lesions  in  the  brain,  such  as 
headache,  vertigo,  mental  impairment,  paralysis  of  one  or  more  cranial 
nerves,  particularly  those  supplying  the  muscles  of  the  eye,  or  optic  neu- 
ritis. Mydriasis  has  also  been  observed.  The  presence  of  any  of  these 
latter  symptoms  confirms  the  diagnosis  of  syphilis,  which  is  ordinarily  less 
clear  in  this  than  in  other  nervous  affections  of  specific  origin.  Careful 
inquiry  into  the  history  and  age  of  the  patient  is  demanded.  Simple  idio- 
pathic paraplegia  generally  occurs  later  in  life  than  the  syphilitic  form, 
and  the  latter,  like  all  specific  nervous  afi'ections,  is  greatly  influenced  and 
frequently  cured  by  treatment,  which  should  be  adopted  early  in  all  cases, 
even  in  those  of  doubtful  character. 

The  prognosis,  unless  treatment  has  been  long  delayed,  is  favorable. 

The  causes  of  syphilitic  paraplegia  are  lesions  of  the  vertebriB,  of  the 
spinal  meninges,  and  tumors  which  by  pressure  on  the  cord  lead  to  mye- 
litis and  softening. 

Cases  thus  far  observed  indicate  that  paraplegia  is  a  later  manifestation 
of  syphilis  than  hemiplegia  and  epilepsy,  though  probably  the  lesions 
which  cause  it,  may  be  developed  as  early  as  within  the  first  year  of  syph- 
ilis. In  the  majority  of  recorded  cases  its  invasion  has  occurred  after 
the  sixth  year  of  infection.     It  may  of  course  occur  very  much  later. 

Aphasia. 

Various  disturbances  of  speech,  included  under  the  term  aphasia,  fre- 
quently occur  in  the  course  of  syphilis  of  the  nervous  system.  These  may 
consist  merely  of  hesitation  in  speaking,  called  embarras  de  parole,  or  of 
inability  to  remember  certain  words  in  writing  and  in  speaking,  or  of  the 
use  of  utterly  inappropriate  words  on  all  occasions. 

Keyes  and  Van  Buren  have  reported  an  interesting  case  of  a  man,  who, 
prior  to  an  attack  of  syphilitic  hemiplegia,  spoke  English  and  French, 
besides  German,  his  native  language,  but,  during  recovery,  he  could  speak 
only  French. 

Syphilitic  aphasia  may  be  continuous  or  intermittent,  and  always  ac- 
companies other  symptoms,  which  determine  its  origin,  since  it  presents  in 
itself  no  diagnostic  features. 

The  prognosis  depends  to  a  great  extent  upon  the  early  adoption  of  anti- 
syphilitic  treatment. 


PSEUDO-GENERAL    PARALYSIS.  G61 


Locomotor  Ataxia. 


Although  so  eminent  an  authority  as  Fournier  claims  that  syphilis  may 
be  the  cause  of  locomotor  ataxia,  we  are  inclined  to  hold  the  contrary 
opinion,  which  has  the  support  of  many  prominent  observers.  Locomotor 
ataxia  is  known  to  be  caused  by  sclerosis  of  the  posterior  columns,  a  lesion 
exactly  limited  to  this  portion  of  the  cord,  though  often  involving  it  to  a 
considerable  extent.  The  lesions  of  syphilis,  on  the  contrary,  are  patchy, 
and  less  diffused,  and,  moreover,  always  originate  in  investing  structures, 
subsequently  involving  the  cord  itself.  The  staggering  gait,  lack  of  co-or- 
dination, darting  pains,  and  muscular  spasms,  caused  by  syphilis,  may 
suggest  locomotor  ataxia;  but  the  slow,  definite  progress  of  the  latter 
affection,  compared  with  the  irregular  grouping  and  uncertain  course  of 
syphilitic  symptoms,  renders  the  distinction  clear. 

Chorea. 

The  spasmodic  muscular  movements  caused  by  syphilis  are  irregular 
and  occasional,  and  never  constitute  complete  chorea.  Pre-paralytic  cho- 
rea, chai'acterized  by  spasmodic  contractions,  without  loss  of  consciousness, 
preceding  an  attack  of  hemiplegia  or  paraplegia,  has  been  already  referred 
to ;  similar  contractions  not  infrequently  follow  these  paralyses,  and  the 
condition  is  then  called  post-paralytic  chorea. 

The  spasms  vary  in  intensity  from  a  mere  twitch  to  a  decided  convul- 
sion, and  may  be  limited  to  an  arm,  or  may  at  the  same  time  include  the 
face  ;  or  they  may  occur  unilaterally  in  the  arm  and  the  leg.  They  do  not 
as  a  rule  become  general,  and  always  coexist  with  other  symptoms  of 
graver  importance. 

Pseudo-gexeral  Paralysis. 

The  relation  of  sypliilis  to  general  paralysis  of  the  insane  has  been  until 
recently  a  disputed  question.  While  some  authorities  claimed  that  the 
latter  affection  was  in  a  measure  due  to  syphilis,  others  believed  that  its 
occurrence  in  a  syphilitic  subject  was  a  mere  coincidence.  The  subject 
has  lately  been  carefully  studied  by  INIickle^  and  Fournier,^  who  have 
arrived  at  the  conclusion  that  syphilis  does  produce  an  affection  resembling 
in  certain  respects  the  general  paralysis  of  the  insane,  but  that  the  two 
diseases  are  not  identical. 

This  affection,  to  wliich  Fournier  gives  the  name  pseudo-general  paraly- 
sis of  sijphilltic  origin,  consists  of  an  association  of  intellectual,  sensory, 
and  motor  disturbances,  evidenced  by  numerous  and  complex  symptoms. 
The  intellectual  disorder  is  indicated  by  cerebral  excitement  and  exaltation 
of  ideas  with  incoherence,  and  by  gayness  of  spirits  alternating  with  hebe- 

'  Brit,  and  For.  Med.-Chir.  Rev.,  Lond.,  July  and  October,  1876  ;  April,  1877. 
2  La  syphilis  du  cerveau,  Paris,  1879,  p.  333. 


662  AFFECTIONS    OF    THE    NERVOUS    SYSTEM. 

tude,  together  with  delirium  and  even  mania.  The  motor  disturbances 
are  well  marked,  and  consist  of  uncertain  movements  without  paralysis, 
trembling,  and  imperfect  prehensile  power  of  the  hands,  sudden  loss  of 
equilibrium,  imperfect  co-ordination,  staggering  gait,  and  hesitating  speech. 
Besides  these  there  are  frequently  special  affections,  such  as  ti'emblings  of 
muscles  and  partial  paralysis,  ephemeral  or  persistent,  and  also  certain 
symptoms  of  cerebral  congestion;  of  the  latter  may  be  mentioned,  a  sense 
of  weight  and  pain  in  the  head,  dizziness,  sudden  dazzling  sensations, 
vertigo,  and  various  impairments  of  sight  and  hearing  ;  to  these  should  be 
added  epileptic  and  epileptiform  convulsions,  and  sudden  seizures  of  an 
apoplectic  character.  Of  course,  we  never  meet  with  all  the  above  symp- 
toms combined,  but  in  all  cases  many  of  them  are  associated. 

The  peculiarities  of  this  syphilitic  affection  are  that  the  paralytic  symp- 
toms predominate ;  that  symptoms  appear  in  a  capricious  and  irregular 
manner,  fibrillary  contractions  of  the  facial  and  lingual  muscles  being 
absent ;  that  there  are  no  well-defined  exalted  ideas ;  and  that  behind  all 
there  is  generally  a  syphilitic  cachexia. 

After  considering  the  subject  exhaustively  and  criticizing  the  loose 
manner  in  which  the  term  "syphilitic  insanity"  is  used,  Mickle  gives  the 
following  points  of  differential  diagnosis  between  true  general  paralysis  and 
the  pseudo-general  paralysis  of  syphilis  : — 

1.  Distinct  history  or  symptoms  of  syphilis. 

2.  Preceding  cranial  pains,  nocturnal  and  intense. 

3.  Exaltation  less  marked,  less  persistent,  and  pei'haps  less  associated 
with  general  maniacal  restlessness  and  excitement. 

4.  Sometimes  complicated  by  palsies  of  one  or  more  cranial  nerves,  or 
by  hemiplegia,  para[)legia,  etc.,  having  the  character  and  course  of  syphi- 
litic palsies. 

5.  The  greater  frequency  of  optic  neuritis,  early  amaurosis,  deafness, 
local  anjesthesiir;,  vertigo,  and  local  rigid  contraction. 

G.  The  affection  of  tlie  articulation  is  paralytic  rather  than  paretic,  and 
usually  speech  is  not  accompanied  by  any  facial  or  labial  tremors. 

7.  Cerebral  or  spinal  meningitis  or  pachymeningitis. 

8.  Great  variety  of  motor  and  sensory  symptoms,  their  capricious  asso- 
ciation or  succession  and  their  transitory  character,  and  the  absence  of 
general  progressive  muscular  paresis. 

9.  Effect  of  anti-syphilitic  treatment. 

Mickle  adds  that  in  the  simple  aftection  the  faradic  contractility  of  the 
muscles  of  the  extremities  becomes  considerably  and  pi'ogressively  lessened, 
while  in  syphilis  it  is  normal  or  but  slightly  impaired. 

Treatment. 

In  the  treatment  of  the  nervous  affections  caused  by  syphilis,  and  espe- 
cially those  involving  the  brain  and  si)inal  column,  there  must  be  no  half- 
way measures.  A  fraction  of  a  grain  of  corrosive  sublimate  or  three  to  five 
grains  of  the  potassium  iodide,  administered  three  times  a  day,  will  do  no 


TREATMENT.  663 

more  good  than  would  the  water  in  which  tliey  are  dissolved.  If  the 
patient's  life  is  to  be  saved,  or  at  least  serious  and  permanent  consequences 
be  averted,  iodine  and  mercury  must  be  used  in  heroic  doses. 

If  the  patient  has  not  already  taken  the  iodide  of  potassium,  it  may  be 
well  to  commence  with  the  moderate  dose  of  fifteen  grains  (1.00)  after  each 
meal,  for  fear  he  may  be  one  of  those  exceptional  individuals  in  whom  the 
iodides  exercise  a  poisonous  influence,  and  if  he  is  found  to  bear  it  well, 
the  dose  should  be  rapidly  increased.  But  when  his  tolerance  has  already 
been  tested,  a  dose  of  half  a  drachm  (2.00),  or,  in  urgent  cases,  even  a 
drachm  (4.00),  three  times  a  day,  is  not  too  much  to  commence  with,  and 
it  should  be  increased — say,  by  the  addition  of  five  grains  (0.30)  every 
other  day — until  amelioration  of  the  symptoms  takes  place  or  at  least  two 
drachms  (8.00)  for  each  dose  have  been  reached.  At  the  same  time  free 
mercurial  inunction  every  night  should  not  be  neglected.  For  more  minute 
directions  we  would  refer  to  our  chapter  on  the  treatment  of  syphilis. 


664  SYPHILITIC    AFFECTIONS    OF    THE    MUSCLES. 


CHAPTER    XXI. 

SYPHILITIC    AFFECTIONS    OF    THE    MUSCLES    AND 
THEIR  ACCESSORIES. 

Syphilitic  affections  of  the  muscles,  although  noticed  by  Astruc,^ 
attracted  but  little  attention  until  investigated  duj-ing  the  present  century, 
more  especially  by  Boyer,^  Ricord/  Bouisson,*  Notta,^  and  Virchow.® 
The  most  important  contributions,  however,  to  this  subject  are  the  elabo- 
rate lectures  by  Mauriac,''  published  within  a  year. 

Syphilis  affects  the  muscles  in  two  ways:  1,  by  an  abnormal  develop- 
ment of  the  connective  tissue  in  the  inter-fibrillar  spaces — the  diffuse 
form;  2,  by  the  deposit  of  gummy  material  in  circumscribed  masses — 
muscular  tumors. 

Diffuse  Form.  Muscular  Contraction — According  to  Virchow, 
this  lesion  is  analogous  to  that  produced  by  rheumatic  inflammation.  "In 
the  interspaces  between  the  muscular  fasciculi,  a  connective  tissue  is  de- 
veloped, which  hardens  and  results  in  atrophy,  and  finally  in  the  destruc- 
tion of  the  primitive  muscular  fibrils."  We  thus  find  at  the  outset  the 
presence  of  abnormal  nuclei,  cells,  and  fibres  in  the  cellular  tissue,  and 
afterwards  a  secondary  degeneration  of  this  new  formation,  resulting  in 
atrophy  of  the  normal  elements,  contraction  of  the  muscle  itself,  and,  in 
some  instances,  calcareous  and  bony  deposits.  This  lesion  usually  escapes 
observation  until  the  contraction  of  the  muscle,  interfering  Avith  motion 
or  producing  flexion  of  the  limb,  attracts  attention. 

One  or  more  muscles  may  be  attacked.  Those  most  frequently  affected 
are  the  flexors  of  the  upper  extremity,  and  especially  the  biceps.  Notta 
met  with  six  cases,  in  two  of  which  tlie  disease  was  confined  to  the  biceps; 
in  two  others,  to  the  biceps  and  supinator  longus ;  and  in  the  remaining 
case  to  the  flexors  of  the  fingers.  The  biceps  has  been  affected  with  the 
same  frequency  in  the  cases  reported  by  other  observers. 

'  A  Treatise  of  Venereal  Disease,  etc.,  translated  from  the  Latin,  London,  1754, 
vol.  ii,  p.  15. 

2  Traite  pratique  de  la  syphilis,  Paris,  183(5. 

3  Notes  to  Hunter,  2d  Am.  ed.,  1859,  p.  45S. 

*  Gaz.  nied.  de  Paris,  1846,  p.  211,  and  Trihut  a  la  chir.  moderne,  t.  i,  1858,  p. 
527. 

5  Mem.  sur  la  retraction  mixscul.  syph.,  Arch.  gen.  de  med.,  Dec.  1850,  4e  sSrie, 
t.  xxiv,  p.  413. 

°  La  syphilis  constitutionello,  p.  105. 

"  Le9ons  sur  les  myopathies  syphilitiques,  Paris,  1878. 


DIFFUSE    FORM.  G65 

In  each  of  the  ten  cases  reported  by  Maui-iac  the  biceps  was  the  seat  of 
this  aftection ;  in  nine  it  was  the  only  muscle  involved,  while  in  one  case 
the  triceps  was  attacked  at  the  same  time.  In  seven  of  these  cases  the 
left  biceps  was  affected,  in  two  both  right  and  left,  and  in  only  one  was 
tlie  muscle  of  the  right  side  alone  affected.  When  both  biceps  and  triceps 
are  involved  muscular  anchylosis  of  the  elbow  results. 

The  contraction  comes  on  insidiously,  and  the  first  symptom  noticed  by 
the  patient  is  an  inability  to  extend  the  limb.  On  examining  the  affected 
muscle,  no  change  is  perceptible  by  palpation  either  in  its  size  or  texture ; 
its  power  of  contraction  is  normal ;  and  there  is  simply  a  diminution  in 
length,  as  shown  by  its  tension  when  the  limb  is  forcibly  extended.  The 
tendon  of  insertion  of  the  biceps  is  always  prominent  and  tense,  and  the 
muscle  itself  appears  to  be  in  a  state  of  partial  contraction. 

In  neither  of  Xotta's  six  cases  was  the  flesliy  portion  of  the  muscle 
sensitive  to  pressure;  but  in  five,  pain  was  excited  by  pressing  upon  one 
or  both  of  the  tendinous  insertions,  and  by  forced  extension. 

According  to  Mauriac  spontaneous  pain  was  absent  in  some  cases,  while 
in  others  the  muscle  was  the  seat  of  a  dull  aching  sensation,  which  was 
subject  to  exacerbations.  In  other  instances  the  patients  suffered  from 
neuralgia  of  the  muscle  or  other  parts.  The  contraction  increases,  slowly 
in  most  cases,  but  rapidly  in  some,  up  to  a  certain  point,  -when  it  remains 
stationary.  In  five  cases  in  which  the  biceps  was  affected,  the  angle 
formed  by  the  arm  and  forearm,  when  the  latter  was  extended  to  the 
utmost,  measured  160°,  135°,  135°,  130°  and  90°,  respectively.  In 
another  case,  the  ring  and  little  fingers  were  completely  flexed  upon  the 
palm  of  the  hand. 

In  none  of  Notta's  cases  had  the  patients  ever  suffered  from  rheuma- 
tism, which,  therefore,  could  have  had  no  part  in  producing  the  muscular 
contraction  ;  but  all  presented  unquestionable  syphilitic  symptoms,  which, 
in  three,  belonged  to  the  tertiary;  in  two  to  the  secondary;  and  in  one  to 
both  the  secondary  and  tertiary  periods. 

]\Iauriac,  however,  regards  this  as  a  precocious  rather  than  a  tertiary 
affection.  He  has  observed  it  as  early  as  the  second  and  as  late  as  the 
fifteenth  month  of  syphilis,  and  thinks  that  we  may  fix  upon  the  tenth 
month  as  the  average  date  of  its  appearance.  It  occurs  in  the  mild  rather 
than  in  the  severe  cases  of  syphilis.  He  thinks  that  rheumatism  has  no 
etiological  relation  to  this  affection,  which  is  myo-neuropathic  in  its  nature  ; 
in  other  words,  syphilis  affects  the  peripheral  nerves  and  muscles.  The 
intensity  of  the  diathesis  has  slight  infiuence  upon  its  development;  of 
nine  cases  but  one  was  severe,  five  were  mild,  and  three  were  of  medium 
severity.  It  is  accompanied  by  non-ulcerative  more  frequently  than  by 
ulcerative  lesions. 

This  affection  may  last  months  or  years,  and  while  it  yields  with  mode- 
rate [)romptness  to  treatment,  it  is  capable  also  of  spontaneous  cure.  Its 
course  is  not  always  uniform,  since  it  is  liable  to  remissions  and  relapses. 
Mauriac  believes  the  lesion  to  be  a  subacute  myositis.     He  passed  a  gal- 


G66  SYPHILITIC    AFFECTIONS    OF    THE    MUSCLES. 

vanic  current  through  muscles  thus  atFectetl,  and  found  impairment  of 
motion  and  of  sensation. 

Under  the  name  of"  chronic  syphilitic  tetanus,"  Deville^  has  reported  a 
case  in  which  a  large  number  of  muscles  were  involved,  and  death  ensued 
from  contniction  of  the  muscles  of  the  pharynx,  which  was  impassable  to 
a  probang.  Kotta  coincides  with  Deville  in  regarding  the  disease  as 
syphilitic. 

In  the  opinion  of  Maiu'iac,  syphilis  plays  an  insignificant  part,  or  per- 
haps no  part  at  all  in  the  production  of  this  affection.  He  looks  upon  it  as 
tetanus,  nevrose  tetaniforme  yeneralisee,  occurring  in  a  syphilitic. 

The  treatment  of  this  affection  consists  in  the  combined  administration 
of  mercurials  and  the  iodide  of  potassium.  Friction  with  stimulating  lini- 
ments and  inunctions  of  mercurial  ointment  have  proved  beneficial  in  our 
experience.  Brisk  rubbing  and  massage  may  also  be  tried  with  the  daily 
use  of  the  Faradic  current.  As  is  true  of  other  syphilitic  symptoms,  the 
disease  is  likely  to  return  if  treatment  be  suspended  too  soon. 

Muscular  Tumors Our  knowledge  of  syphilitic  tumors  of  the  mus- 
cles, is  due  in  a  great  measure  to  M.  Bouisson,  late  Prof,  of  Surgery  at 
Montpellier. 

These  tumors  are  dependent  upon  circumscribed  deposits  of  the  same 
material  as  is  found  in  gummata  of  the  subcutaneous  cellular  tissue,  and 
in  most  of  the  syphilitic  affections  of  the  viscera. 

Gummy  tumors  have  been  met  with  in  the  glutoeus  maximus,  trapezius, 
sterno-cleido-mastoideus,  vastus  extern  us,  pectoralis  major,  and  some 
other  muscles  ;  and  in  the  walls  of  the  heart  by  Ricord,'  Lebert,^  and 
Virchow.^  Tubercles  of  the  tongue  are  frequently  seated  in  the  muscular 
as  well  as  in  the  cellular  tissue  ;  and  many  of  the  sloughing  idcers  of  the 
velum  palati,  pharynx,  and  larynx,  commence  as  gummy  tumors  of  the 
neighboring  muscles,  the  mucous  membrane  being  involved  secondarily. 
Mention  has  also  been  made  of  similar  tumors  in  the  lips,  which  are  said 
to  have  been  mistaken  for  epithelial  cancer,  but  doubt  may  be  entertained 
whether  they  were  not  merely  the  induration  underlying  labial  chancres. 

With  regard  to  their  mode  of  origin  Bouisson  says  :  "  It  is  difficult  to 
determine  whether  the  earliest  changes  take  place  in  the  muscular  fibrils 
or  in  the  intervening  cellular  tissue ;  although  analogy  Avould  lead  us  to 
believe  that  it  is  the  fibro-cellular  element  connecting  the  fleshy  fibres  or 
serving  as  their  sheath,  which  is  first  involved.  But  in  advanced  cases — 
no  matter  what  the  mode  of  termination,  whether  by  suppuration  or  indu- 
ration— all  the  anatomical  elements  appear  to  be  affected  ;  and,  according 
to  the  progress  of  the  morbid  action,  the  muscular  fibres  are  either  sur- 
rounded by  a  material  of  new  formation  or  are  softened  and  destroyed,  or, 

'  Riill.  Soc.  anat.  de  Paris,  1845,  p.  276. 

2  Icoiiographie,  pi.  XXIX. 

3  Traite  cVAnatomie  Pathologique,  t.  i,  PI.  LXVIII.  Fig.  5. 
*  La  Syphilis  Constitutioiielle,  p.  108. 


MUSCULAR    TUMORS.  6G7 

again,  are  transformed  into  indurated,  sub-cartilaginous  or  even  osseous 
tissue.  Such  at  least  are  the  different  stages  I  have  met  with  in  these 
tumors. 

"  In  the^rs^  sfar/e,  the  muscle  is  the  seat  of  a  local  and  cii'cumscribed 
swelling,  of  greater  consistency  than  oedema.  Upon  a  cut  surface  of  the 
diseased  tissue  we  can  recognize  decolorized  muscular  fasciculi  in  the  midst 
of  a  plastic  effusion  of  a  grayish  color. 

"  In  the  second  stage,  the  adventitious  deposit  softens,  and,  if  the  attend- 
ant inflammation  continues  of  a  chronic  character,  is  transformed  into  a 
viscid,  stringy  liquid,  resembling  a  solution  of  gum.  If,  on  the  contrary, 
acute  inflammation  sets  in,  or  if  the  tumor  has  been  attended  from  the  out- 
set with  constant  pain  and  an  increase  of  temperature,  pus  (?)  is  formed  in 
the  centre  of  the  muscle,  the  fibres  are  softened  and  destroyed,  and  more 
or  less  disorganization  takes  place. 

"  In  the  third  stage,  those  syphilitic  tumors  of  the  muscles  which  do  not 
suppurate,  become  indurated.  Like  periostoses,  they  pass  through  suc- 
cessive stages  of  organization,  and  from  being  firm,  become  sub-cartilagi- 
nous, cartilaginous,  and  osseous.  This  final  transformation,  from  its 
peculiarity  and  persistency,  has  especially  attracted  the  attention  of  patholo- 
gists. I  have  seen  a  very  remarkable  example  of  it  in  the  museum  of  the 
Faculty  of  Medicine  at  Strasbourg — an  osseous  mass  of  very  considerable 
size  developed  in  the  substance  of  the  quadratus  femoris.  Ossifications  of 
the  muscles  and  their  tendons  have  frequently  been  observed  in  syphilitic 
persons  with  exostoses  on  various  parts  of  the  body.  In  the  collection  of 
my  colleague,  Prof.  Dubrueil,  is  the  skeleton  of  an  Arab  who  was  affected 
with  syphilis,  and  in  whom,  besides  numerous  exostoses,  there  was  ossifi- 
cation of  a  large  number  of  muscles  at  the  points  of  their  insertion." 

Tliis  "  third  stage,"  recognized  by  Bouisson,  should  rather  be  regarded  as 
the  termination  of  those  muscular  tumors  which  do  not  undergo  softening. 

More  recent  authorities  also  deny  Bouisson's  assertion  that  these  tumors 
may  terminate  in  suppuration;  thus,  Lancereaux  {op.  cit.  p.  2G1)  says: 
"  It  is  very  evident  that  this  author  has  mistaken  for  suppuration  either  a 
muscular  lesion  consecutive  to  changes  in  neighboring  bone,  or  else  the 
results  of  fatty  transformation  of  the  plastic  elements  of  the  gummy  tumors 
themselves  ;  the  suppuration  was  not  the  effect  of  sy[)hilis." 

Mauriac  also  states  that  they  never  terminate  in  suppuration  and  con- 
siders this  an  important  point  in  the  diagnosis. 

Tliese  tumors  vary  in  size  from  that  of  a  filbert  to  an  orange  ;  they  are 
usually  globular  in  shape ;  the  integument  covering  them  is  unaffected. 

Tliey  grow  slowly  and  vvitliout  inflammatory  symptoms,  and  at  first 
cause  no  inconvenience.  They  are  of  various  shapes,  globular,  fusiform, 
or  irregular,  according  to  the  nature  of  the  parts  in  wliich  they  are  seated. 
When  superficial  they  become  adherent  to  the  aponeurosis  which  becomes 
inflamed  and  hypertropliied.  Being  frequently  developed  near  the  ends  of 
tli'e  muscles,  the  tendons  are  sometimes  secondarily  involved. 

They  are  most  easily  detected  when  the  muscle  is  relaxed,  and  their 
independence  of  the  subjacent  bone  can  then  be  best  established.      They 


668  SYPHILITIC    AFFECTIONS    OF    THE    MUSCLES. 

excite  little  or  no  pain  unless  tlve  muscle  be  put  upon  the  stretch,  and  their 
chief  inconvenience  is  due  to  their  interference  with  motion.  They  some- 
times produce  contraction  of  the  muscle,  but  this  is  not  a  necessary  result. 

They  usually  a[)pear  late  in  the  disease,  but  Mauriac  has  seen  them  in 
three  cases  as  early  as  three  and  five  months  after  infection,  while  we  have 
observed  a  tumor  in  the  sterno-mastoid  muscle  in  the  fourteenth  month  of 
syphilis. 

Tliey  are  almost  always  accompanied  by  other  sy|)hilitic  manifestations, 
as  nodes,  exostoses,  tubercles  of  the  cellular  tissue,  or  ulcerations  of  the 
fauces. 

Their  prognosis  is  good  particularly  if  they  are  attended  to  early,  and 
their  treatment  is  that  of  the  advanced  stages  of  the  disease,  viz.,  by  means 
of  the  iodide  of  potassium  and  tonics,  either  associated  with,  or  followed  by, 
mercurials. 

Contraction  of  the  Jaws. — Under  this  title  Guyot  and  Beauvette 
describe  a  number  of  cases,  in  which  there  was  inability  to  separate  the 
jaws  and  swelling  of  the  masseter  muscle.  In  some  cases  there  is  no 
history  of  syphilis  and  in  none  is  the  affection  clearly  of  syphilitic  origin. 
Mauriac  remarks  of  two  of  Guyot's  cases  that  the  muscles  at  the  end  of 
three  years  had  not  become  sufficiently  altered  to  render  treatment  ineffi- 
cacious. Guyot  says  that  syphilitic  myositis  of  the  masseter  muscle  is 
difficult  of  diagnosis,  since  it  may  be  confounded  with  a  similar  condition 
caused  by  cold  or  hysteria. 

Its  actual  nature  must  be  determined  by  careful  examination  of  the  parts 
and  from  the  history  of  the  case.  He  also  suggests  that  several  cases  of 
contracture  of  the  masseter,  re})orted  as  incurable,  were  really  syphilitic, 
and  might  have  been  cured  in  an  early  stage. 

Affections  of  the  Tendinous  Sheaths  and  of  the  Tendons 
AND  Aponeuroses. 

For  our  knowledge  of  these  affections  we  are  indebted  chiefly  to  Ver- 
neuiP  and  Fournier'*.  Under  the  name  "  dorsal  hygroma,"  the  former 
describes  certain  swellings  which  occur  on  the  backs  of  tlie  hands.  These 
swellings  follow  the  course  of  the  tendons  but  never  extend  beyond  the 
dorsal  ligament ;  they  are  of  triangular  shape  with  their  base  towards  the 
fingers.  They  are  due  to  effusion  and  yield  a  sensation  of  fluctuation;  they 
cause  little  if  any  pain,  unless  of  unusually  large  size,  when  the  skin  over 
them  may  be  inflamed  and  painful.  They  occur  in  the  early  years  of  sy- 
philis and  are  developed  rapidly. 

Fournier  describes  an  affection  of  the  tendons  of  the  wrist,  ankle,  foot, 
etc.,  and  says  that  any  tendon  may  be  thus  attacked.      The  lesion  is  a 

'  De  I'hydropisie  des  gaines  tendineuses  dos  extenseurs  des  doigts  dans  la  sy- 
philis secondaire.     Gaz.  hebd.  de  med.,  Paris,  Sept.  25,  18(38. 

2  Note  sur  les  lesions  des  gaines  tendineuses  dans  la  syphilis  secondain;  ;  Gaz. 
hebd.  de  med.,  Oct.  9,  1868. 


AFFECTIONS    OF    THE    BURS.E.  669 

hyperoemia  of  the  sheath  attended  by  serous  effusion.  The  shape  of  the 
resulting  tumors  varies  according  to  the  conformation  of  the  parts. 

They  are  firm  and  ehastic  and  sometimes  fluctuate.  Tlie  overlying  skin 
is  frequently  reddened.  They  form  rapidly  and  are  often  attended  with 
pain.  Fournier  believes  that  many  of  the  early  pains  of  syphilis  are  due 
to  hyperjemia  of  the  sheaths  of  the  tendons,  and  especially  that  the  pain 
sometimes  present  in  the  bend  of  the  elbow,  intensified  by  firm  pressure, 
is  due  to  inflammation  of  the  tendon  of  the  biceps. 

Tendons  may,  in  rare  cases,  be  the  seat  of  gummy  infiltrations,  which 
exist  in  the  form  of  small  subcutaneous  tumors,  usually  unattended  by 
spontaneous  pain.  After  remaining  indolent  for  a  long  time,  they  may 
break  down  and  form  troublesome  ulcers.  Van  Oort  cites  a  case  of  gummy 
tumor  of  the  third  extensor  tendon,  seated  over  the  middle  of  the  meta- 
carpal bone.  Such  a  tumor  might  be  mistaken  for  simple  ganglion.  When 
the  tendon  is  attacked  near  a  joint  the  latter  may  be  secondarily  involved. 

The  tendons  are  more  subject  to  syphilitic  changes  near  their  insertion 
and  in  their  thicker  portions.  The  larger  tendons  and  those  most  con- 
stantly in  use  are  most  frequently  involved.  Sabail  reports  a  case  of  gummy 
tumor  involving  the  tendo  Achillis  of  each  leg.  Nelaton  has  twice  found 
them  in  the  tendon  of  the  ti-iceps  cruris,  and  cases  are  on  record  in  which 
the  ligamentum  patellje,  the  tendon  of  tlie  sterno-mastoid  muscle,  tlie  an- 
terior tendon  of  the  thigh  and  the  flexor  tendons  of  the  legs,  were  thus 
affected.  Finally  Bouisson  has  reported  a  case  of  strabismus  due  to  a 
gummy  tumor  in  the  tendon  of  one  of  the  orbital  muscles. 

Syphilitic  tumors  of  the  aponeuroses  are  less  salient  and  less  circum- 
scribed than  those  of  the  tendons.  They  consist  of  thickening  of  these 
fibrous  envelopes  and  are  prone  to  attack  the  dense  fasciae  of  the  limbs, 
particularly  the  fascia  lata.  These  tumors  run  a  course  similar  to  that  of 
tumors  of  the  tendons,  but  they  are  not  very  prone  to  degenerate. 

Affections  of  the  Burs^. 

Our  knowledge  of  the  effect  of  syphilis  upon  the  bursa?  is  still  far  from 
complete.  Some  observers  think  that  congestion  of  these  structures, 
possibly  attended  by  serous  effusion,  may  occur  in  the  secondary  stage  of 
syphilis.  This  view  seems  to  be  sup[)orted  by  the  occurrence  of  rheuma- 
toid pains  in  the  neighboring  parts. 

In  the  tertiary  stage,  affections  of  the  bursaj  are  quite  frequent.  The 
bursae  over  the  patella?  are  most  commonly  attacked.  The  lesion  is  a  gum- 
mous  infiltration  with  formation  of  connective  tissue.  It  begins  insidiously 
and  without  pain  ;  the  patient's  attention  is  first  attracted  by  a  Iiard  mov- 
able lump  beneath  the  skin.  It  varies  in  size  and  shape  in  different  bursa?. 
Over  the  knee-joint  we  have  found  tumors  as  large  as  a  walnut  or  as  an 
egg.  The  tumor  may  remain  indolent  for  a  long  lime  giving  very  slight 
discomfort.  In  some  cases  it  is  excessively  hard,  in  others  it  is  (piitc 
elastic.  Sometimes  the  parts  seem  to  be  infiltrated  with  fluid.  If  not 
treated,  and  [)articularly  if  subjected  to  irritation,  the  tumor  grows  and 


670  SYPHILITIC    AFFECTIONS    OP    THE    MUSCLES. 

becomes  adherent  to  the  overlying  skin.  Inflammatory  symptoms  appear 
and  the  integument  over  the  bursa  ulcerates.  The  inflamed  and  infiltrated 
bursa  may  sometimes  be  seen  at  the  base  of  the  ulcer.  Under  such  cir- 
cumstances the  coui'se  of  the  lesion  is  very  tedious.  In  other  cases,  even 
of  very  large  tumors,  treatment  causes  their  absorption  within  two  or  three 
months.  The  lesion  may  be  unilateral  but  frequently  attacks  both  patellar 
bursa?.  In  many  cases  traumatism  is  an  important  exciting  cause  ;  in 
others  the  bursoe  are  secondarily  involved  by  the  extension  of  gummatous 
infiltration  from  adjacent  parts,     Eelapses  are  quite  frequent. 

Keyes  who  has  written  an  excellent  paper  on  this  subject  has  collected 
twelve  cases  ;  in  three,  the  bursa?  of  both  patellae  were  involved  and  in  two 
the  bursa  of  one  patella  only  was  affected ;  that  over  the  tuberosity  of  the 
tibia  once;  that  between  the  inserLion  of  the  semitendinosusand  the  lateral 
ligament  of  the  knee,  double  once  and  single  once.  In  the  other  four  cases 
the  bursitis  was  unilateral,  once  over  the  malleolus,  once  beneath  a  corn, 
once  in  the  palm  of  the  hand,  and  once  over  the  olecranon.  It  occurs  most 
commonly  in  women  and,  according  to  Keyes,  at  an  average  age  of  thirty- 
five  years.  It  may  appear  within  one  year  after  infection,  as  in  two  cases 
now  under  our  care,  but  it  is  usually  a  late  manifestation,  being  developed 
after  the  fifth  year.  In  a  third  case  of  our  own,  ten  years  have  elapsed  since 
infection. 

The  treatment  should  be  both  internal  and  local.  In  quite  a  large  ex- 
perience we  have  obtained  good  results  from  the  mixed  treatment.  Mer- 
curial ointment  externally  hastens  absorption  of  the  subcutaneous  tumors. 
In  the  ulcerative  stage  the  neoplasm  must  be  destroyed  by  caustics,  of 
which  potassa  fusa  is  the  most  effective.  Its  application  should  be  repeated 
as  the  case  demands.  The  patient  must  be  kept  in  bed  and  excessive  re- 
action prevented  by  water-dressings.  The  subsequent  treatment  is  similar 
to  that  of  gummous  ulcers. 


AFFECTIONS    OF    THE    FINGERS    AND    TOES.  671 


CHAPTER    XXII. 

AFFECTIONS    OF    THE    FIXGERS    AND    TOES. 
DACTYLITIS    SYPHILITICA. 

Besides  being  the  seat  of  primary  and  secondary  lesions,  the  fingers 
and  toes  are,  in  the  tertiary  period,  attacked  by  gummy  deposit  in  their 
subcutaneous  connective  tissue  and  by  infiltration  and  inflammation  of 
their  bones.  This  affection  was  little  known  until  recently,  and  was  for- 
merly called  syphilitic  panaris.  .  We  use  the  term  dactylitis,  derived  from 
the  Greek  SaxrvXoj,  a  digit  or  finger,  as  being  more  correct  and  expressive. 

To  Chassaignac,  in  1859,  is  due  the  credit  of  first  calling  attention  to 
it,  but  his  description  was  vague.  In  1860,  Nelaton,  in  a  clinical  lecture, 
reported  one  case  and  referred  to  another.  In  1866,  Prof.  LUche,  of 
Berne,  published  two  cases;  in  1869,  Archambault  one;  in  1870,  Yolk- 
mann  and  R.  Bergh,  of  Copenhagen,  each  published  one.  In  1871,  we 
reported  two  new  cases  in  a  monograph,  containing  briefly  all  the  cases 
up  to  that  time  published,  with  a  description  of  the  disease.  Since  then 
we  have  seen  several  cases  in  practice  and  others  have  been  published. 

The  affection  is  caused  both  by  acquired  and  by  hereditary  syphilis. 
The  cases  due  to  the  former  are  much  less  numerous,  there  being  under 
two  dozen  reported  up  to  the  present  time,  whereas  hereditary  dactylitis 
is  by  no  means  uncommon.  In  this  section  the  acquired  form  will  be 
described.  Of  this  there  are  two  vai'ieties  :  first,  that  in  which  the  subcu- 
taneous connective  tissue  and  the  fibrous  structures  of  the  joints  are  in- 
volved ;  second,  that  in  which  the  morbid  process  begins  in  the  bones  and 
periosteum,  secondarily  implicating  the  joints,  and  perhaps  accompanied 
by  deposit  in  the  subdermal  connective  tissues.  These  varieties  are  con- 
stantly found,  and  their  adoption  will  simplify  description.  The  size  of 
the  affected  member  is  materially  increased  and  its  mobility  is  more  or  less 
interfered  with.  The  lesion  comes  on  slowly,  and  first  attracts  the 
patient's  attention  by  the  slight  enlargement  of  one  or  more  fingers  or 
toes.  The  swelling  gradually  increases  and  the  member  becomes  hard  and 
firm.  When  the  toes  are  affected,  tlieir  whole  length  is  generally  included; 
but  when  a  finger  is  attacked,  the  lesion  may  be  quite  sharply  limited  to 
one  phalanx,  almost  invariably  the  proximal  one ;  or  the  adjacent  phalanx 
may  be  involved  to  a  le.ss  degree ;  or,  finally,  the  whole  finger  may  be 
affected.  Fig.  122  shows  this  infiltration  into  the  second  toe  of  the  right 
foot  of  a  patient  wlio  was  under  our  care,  and  whose  history  is  given  in 
full  in  our  original  article. 

A  finger  or  a  toe  thus  attacked  presents  a  reddish,  violaceous  appear- 


672 


AFFECTIONS    OF    THE    FINGERS    AND    TOES. 


ance,  and  to  tlie  touch  is  quite  resistant  and  tense,  the  normal  lines  of  the 
integument  being  effaced.  Unlike  gummy  tumors  developed  Avhere  the  con- 
nective tissue  is  plentiful,  and  which  are  isolable  and  movable,  these  infil- 
trations of  the  fingers  and  toes  are  firmly  attached  to  the  skin,  the  process 


Fig.  122. 


apparently  involving  the  corium  even  to  its  papillary  layer.  In  most  cases 
the  thickening  is  greatest  on  the  dorsal  aspect,  very  rarely  being  equally 
free  on  the  palmar  or  plantar  surface.  The  swelling  ends  abru[)tly  at  the 
nietacarpo-phalangeal  joint. 

These  swellings  are  usually  developed  slowly  and  painlessly,  but  in  some 
cases  a  dull  aching  pain  is  present.  When  the  infiltration  is  complete  it 
is  impossible,  on  account  of  the  density  of  the  tissues,  to  determine  accu- 
rately the  condition  of  the  bones,  although  they  seem  to  be  thickened.  As 
the  affection  subsides,  the  bones  and  joint-structures  can  be  more  thoroughly 
examined,  and  we  then  find  more  or  less  pei'iosteal  thickening.  In  most 
cases,  however,  the  bones  are  quite  superficially  involved,  whereas,  in  the 
second  form  of  dactylitis,  they  are  profoundly  attacked.  It  is  impossible 
to  say  whetlier  the  morbid  process  begins  in  the  periosteum  or  in  the  con- 
nective tissue  over  it;  it  is  certain  that  the  lesion  is  sometimes  sharply 
limited  to  the  tissues  over  one  or  more  phalanges,  and,  again,  it  may  in- 
volve the  whole  member. 

Within  a  few  weeks  after  the  development  of  the  affection,  symptoms 
of  joint  implication  appear.  At  first,  flexion  of  the  joints  is  impaired  by 
the  swelling.     In  the  course  of  one  or  two  months,  if  no  treatment  is  fol- 


DACTYLITIS. 


673 


lowed,  the  joints  become  flaccid  and  unnaturally  mobile.  Sometimes  in 
this  variety  of  dactylitis,  there  is  slight  hydrarthrosis  and  often  crepitation 
in  the  metacarpo-phalaiigeal  joint,  or  between  the  articular  surfaces  of  two 
phalanges.  This  will  be  again  referred  to  in  speaking  of  the  second  form 
of  dactylitis. 

This  gummous  infiltration  of  the  integument  and  periosteum  of  the 
fingers  and  toes  may  be  limited  to  one  of  these  members  or  may  involve 
several.  A  single  hand  or  foot,  or  both,  may  be  involved,  one  or  more 
fingers  and  toes  being  attacked  simultaneously  or  in  succession.  The 
lesion,  being  a  late  manifestation,  very  often  follows  or  accompanies  gum- 
mous infiltrations  elsewhere.  It  runs  a  chronic  course,  and  in  its  early 
stage  is  amenable  to  treatment.  The  fact  that  gummy  tumors  of  these 
parts  are  not  prone  to  ulcerate  is  incapable  of  positive  explanation.  The 
character  of  the  deposit  is  certainly  not  peculiar,  but  it  may  be  that  the 
vascularity  and  density  of  the  tissues  modify  the  course  of  the  lesion.  The 
wonderful  reparative  power  of  the  fingers  after  injury  is  well  recognized. 
This  form  of  dactylitis  generally  results  in  restoration  of  the  atfected 
members,  but  in  neglected  cases  the  joints  may  be  rendered  permanently 
useless  and  the  bones  may  remain  enlarged.  The  nails  either  escape,  or, 
in  very  chronic  cases,  present  minute  transverse  furrows,  indicative  of 
impaired  nutrition. 

The  second  form  of  dactylitis  is  sharply  limited  to  the  bone,  and  is  due 
either  to  specific  periostitis  or  osteo-myelitis.  The  affection  may  progress 
rapidly,  slowly,  or  with  intermissions.  The  earlier  after  infection  the 
lesion  occurs,  the  more  acute  is  its  course.  The  degree  of  its  induration 
is  generally  in  [)roportion  to  the  chronicity  of  its  development:  a  rai)idly 
formed  swelling  may  be  so  soft  as  to  be  susceptible  of  indentation  by  firm 
pressure.  The  affection  may  be  speedily  cured  by  energetic  and  early 
treatment,  but  if  unchecked  it  may  progress  to  an  extreme  degree.  Fig. 
123,  taken  from  Bergh's  case,  gives  an  idea  of  the  size  and  shape  of  a 


Fiff.  123. 


(After  Bergh.) 


swollen  phalanx,  whose  normal  circumference  of  about  two  inches  was 
increased  to  five  by  tiiis  lesion.  A  similar  case  was  under  our  care  several 
years  ago.  It  seems  to  be  the  rule  that  when  only  one  bone  is  affected, 
the  swelling  is  greater  than  when  several  are.  The  shape  of  the  swelling 
depends  upon  the  phalanx  attacked.  When  the  first  is  involved  it  may 
43 


674 


AFFECTIONS    OF    THE    FINGERS    AND    TOES. 


assume  an  acorn-shape  or  the  appearance  of  a  balloon ;  the  second  and 
third  phalanges  may  be  fusiform  or  cylindrical.  In  most  cases  the  whole 
bone  is  involved.  The  disease  may  be  limited  to  the  extremity  of  a 
phalanx  adjacent  to  one  already  the  seat  of  dactylitis. 


Fi-.  124. 


(After  Bergh.) 


The  proximal  phalanx  is  most  frequently,  the  distal  phalanx  least  fre- 
quently, involved.  We  have  seen  in  two  instances  enlargement  of  the 
second  phalanx  only,  and  of  the  third  in  one  case.  In  hereditary  syphi- 
lis it  is  not  uncommon  to  find  swelling  of  the  second  and  even  of  the  third 
phalanges. 

The  fingers  are  attacked  more  commonly  than  the  toes;  in  a  few  cases 
they  have  been  involved  simultaneously.  More  than  one  phalanx  of  the 
same  finger  may  be  affected,  as  well  as  several  fingers,  either  unilaterally 
or  symmetrically.  In  the  latter  case  swelling  of  one  or  more  toes  is  likely 
to  occur  at  the  same  time.  Other  osseous  lesions  may  coexist,  and  articu- 
lar affections  and  gummous  infiltrations  of  the  skin  may  be  associated  with 
these  lesions  of  the  fingers. 

The  metacarpal,  and  less  frequently  the  metatarsal,  bones  become  swollep 
coincidently  with  a  dactylitis,  or  they  alone  may  be  affected.  The  ex- 
tremity adjoining  the  phalanx  or  the  opposite  extremity  may  be  involved. 

The  mode  of  invasion  and  the  course  of  these  swellings  are  similar  in 
the  metacarpal  bones  and  in  the  bones  of  the  fingers.  Tlie  metacarpal 
bones  of  the  thumb  and  index  finger  are  those  most  frequently  the  seat  of 
dactylitis. 

The  integument  is  rarely  infiltrated  in  this  form  of  dactylitis,  gummous 
deposit  having  been  found  in  the  subcutaneous  tissues  in  but  two  cases  of 
primary  lesion  of  the  bones.  The  skin  may  undergo  very  little  change, 
unless  the  swelling  is  excessive,  when  it  becomes  tense  and  thinned,  and 
the  normal  furrows  are  effaced.  AVhen  the  process  is  rapid  the  skin  be- 
comes red  and  inflamed;  when  the  growth  of  the  lesion  is  slow  the  skin 
accommodates  itself,  and  very  slight  if  any  inflammation  occurs.  In 
some  cases  ulceration  takes  place  or  an  incision  is  required  to  relieve  the 
tension.  The  inflammatory  focus  is  always  on  the  sides  of  the  fingers. 
In  case  an  opening  forms  or  is  made,  a  soft  cheesy  detritus  mixed  with 
pus  comes  away.     Necrosis  may  occur,  but  the  destruction  of  bone  tissue 


DACTYLITIS.  675 

is  usually  limitetl,  and  after  a  short  time  the  fistula  closes.  In  the  majority 
of  cashes  resolution  of  the  bony  swelling  takes  place. 

The  joint  structures  are  generally  much  thickened.  After  the  dactylitis 
has  existed  about  a  month,  crepitation  may  be  detected  from  friction  of 
the  articular  surfaces.  This  is  undoubtedly  due  to  erosion  of  the  articular 
cartilages  in  consequence  of  impaired  nutrition.  In  some  cases  an  effu- 
sion into  the  joint  cavity  takes  place,  slowly  and  without  pain.  This 
condition  of  hydrarthrosis  varies  in  degi'ee,  and  may  be  due  either  to  infil- 
tration or  simple  congestion  of  the  synovial  membrane.  This  complica- 
tion is  not  serious,  and  generally  ends  in  absorption.  The  thickening  of 
the  ligaments  and  joint-structures  results  in  impairing  the  motion  of  the 
joints  or  in  rendering  them  preternaturally  mobile. 

These  bony  swellings  may  remain  in  an  indolent  condition  for  a  long 
time,  and  finally  the  gummy  deposit  may  be  absorbed,  or  it  may  soften 
and  be  discharged  through  a  sinus.  The  shaft  of  the  bone  may  resume  its 
normal  size,  or  it  may  be  rendered  thinner  and  lighter,  as  shown  in  the 
accompanying  illustration  of  Bergh's  case  (Fig.  125).     Sometimes  it  is 

Fis.  125. 


(After  Bergh.) 

shortened,  and  in  other  cases  again  it  is  slightly  longer  than  normal.  The 
bone  may  be  left  in  a  condition  of  eburnation,  being  decidedly  thickened. 

The  process  of  involution  may  be  slow  or  quite  rapid,  and  seems  to  be  in 
proportion  to  the  rapidity  of  the  development  of  the  lesion.  In  most  cases 
the  deformity  is  not  very  marked  ;  in  some  cases  of  necrosis  a  less  fortunate 
result  is  obtained  (Fig.  12G).  The  illustration,  taken  from  our  paper  on 
the  subject,  shows  deformity  and  shortening  of  the  index  finger,  so  that  its 
extremity  scarcely  reaches  the  first  phalangeal  joint  of  the  middle  finger. 
In  tiiis  case  the  greater  part  of  tlie  first  phalanx  and  the  distal  extremity 
of  the  metacarpal  bone  had  been  absorbed,  and  the  remnants  of  the  two 
bones  were  connected  by  fibrous  tissue.  In  a  similar  manner  the  second 
phalanx  of  the  ring  finger  had  been  reduced  to  about  one-fourth  of  its 
original  length.  After  the  process  of  absorption  is  complete,  the  contigu- 
ous bones  are  always  united  by  a  ligamentous  band,  which  serves  as  a 
joint.  The  function  of  a  finger  in  sucli  a  condition  is  of  course  greatly 
impaired,  and  excessive  deformity  may  result.  The  manner  in  which  the 
soft  parts  adapt  themselves  to  the  altered  condition  is  very  remarkable, 
their  contraction  being  of  great  service  in  giving  steadiness  and  solidity 
to  till'  false  joints. 

In  spite  of  the  extent  of  the  osseous  lesions,  pain  is  either  very  slight 
or  altogether  absent.     In  no  case  have  the  tendons  or  their  sheaths  been 


G76 


AFFECTIONS    OF    THE    FINGERS    AND    TOEP. 


found  implicated.     The  absorption  of  the  bones  is  unaccompanied  by  ulcer- 
ation of  the  soft  parts. 

This  affection  is  one  of  the  late  manifestations  of  syphilis,  occurring 
usually  between  the  fifth  and  fifteenth  years.  The  average  age  of  its  sub- 
jects has  been  about  forty  years.  Exceptionally,  it  appears  early,  we 
haviner  seen  one  case  in  which  it  occurred  eighteen  months  after  infection. 


The  early  recognition  of  these  two  forms  of  dactylitis  is  important  in 
order  to  prevent  destruction  of  tissue  and  deformity.  The  subcutaneous 
variety  in  its  early  stage  may  be  mistaken  for  paronychia,  but  the  absence 
of  acute  inflammatory  symptoms,  especially  pain,  establishes  the  diagnosis. 
Dactylitis  of  the  great  toe  might  be  mistaken  for  gout,  but  for  the  subacute 
character  of  the  former.  When  several  fingers  and  toes  are  attacked, 
particularly  if  there  is  a  coincident  aflfection  of  one  of  the  larger  joints, 
the  case  may  be  regarded  as  one  of  rheumatoid  arthritis;  but  the  latter  is 
essentially  a  joint-affection,  and  is  quite  painful;  it  attacks  the  metacarpo- 
phalangeal (and  rarely  the  metatarso-phalangeal)  joints  more  frequently 
than  the  phalanges,  and  generally  involves  the  sheaths  of  the  tendons  ; 
sometimes  tophi  are  deposited  in  the  tendons,  especially  of  the  flexors  and 
elsewhere,  as  in  the  cartilages  of  the  ear;  deformity  begins  early,  and 
there  is  a  tendency  of  the  fingers  to  be  drawn  to  the  ulnar  side  of  the 
hand  and  to  be  flexed  and  extended  at  various  angles.  Dactylitis  syphi- 
litica may  be  confounded  with  enchondroma  or  exostosis,  but  in  each  of 
the  latter  the  swelling  is  more  localized,  being  limited  to  a  portion  of  the 
circumference  of  the  bone. 

The  pi'ognosis  depends  in  a  measure  upon  the  period  at  which  the  lesion 
is  recognized.  When  the  swelling  is  developed  quickly,  rapid  involution 
follows  the  use  of  energetic  treatment.  The  longer  it  has  persisted  the 
less  amenable  to  treatment  it  becomes. 

The  treatment  is  that  of  late  syphilis,  a  combination  of  the  iodide  of 
potash  with  a  mercurial ;  locally,  mercurial  ointment  or  plaster  applied 
with  pressure  is  beneficial.     Sometimes  an  incision  is  required. 


PRECOCIOUS    OSSEOUS    AFFECTIONS.  G77 


CHAPTER   XXIII. 

AFFECTIOXS    OF    THE    BONES,    CARTILAGES,    AND 
THE    JOINTS. 

Precocious  Osseous  Affections. 

The  bones  may  be  attacked  in  the  early  months  of  syphilis,  although 
osseous  lesions  are  generally  quite  late.  The  bones  most  liable  to  early 
affection  are  those  of  the  cranium,  the  I'ibs,  the  sternum,  the  clavicle,  and 
the  tibia.  According  to  Mauriac^  these  lesions  may  occur  even  before  the 
cutaneous  manifestations  of  syphilis.  We  have  observed  localized  pain  in 
the  bones  at  the  period  of  invasion,  but  never  distinct  swellings  much  be- 
fore the  sixth  month  of  sypliilis.  The  swellings  appear  quickly  and  with 
fixed  pain  which  is  worse  at  night,  and  may  be  accompanied  by  radiating, 
neuralgic  pains. 

Of  the  skull  bones,  the  frontal  and  parietal  are  most  commonly  attacked. 
The  swellings  vary  in  diameter  from  lialf  an  inch  to  an  incii  and  a  half, 
and  reacli  a  height  of  half  an  inch.  They  are  round  and  smooth,  and  if 
slowly  developed  are  quite  hard.  They  may  be  single  or  multiple,  uni- 
lateral or  symmetrical.  AVe  have  now  under  observation  a  patient  infected 
six  months  ago,  upon  whose  skull  there  are  thirteen  of  these  nodes.  Tiiey 
may  occur  at  the  angle  of  junction  of  the  frontal  bone  with  the  ox'bital 
plates,  or  on  the  occipital  bone,  but  they  are  usually  on  the  sides  of  the 
skull.  Mauriac  states  that  they  are  sometimes  confluent.  In  some  cases 
cerebral  symptoms  indicate  that  similar  lesions  exist  on  the  internal  surface 
of  the  cranium. 

The  clavicle  is  usually  affected  at  its  sternal  extremity,  the  articulation 
sometimes  being  involved.  The  upper  third  of  the  sternum  is  more  com- 
monly involved  than  the  lower  third.  Occasionally  its  borders  are  at- 
tacked with  portions  of  the  costal  cartilages,  when  the  patient  may  com- 
plain of  severe  dyspnoea  and  pain  on  deep  inspiration.  In  such  a  case  a 
localized  pleurisy  has  jjrobably  bf^en  excited.  In  severe  cases  the  ribs 
themselves  may  be  invaded,  especially  their  anterior  portions.  Its  subcu- 
taneous surface  is  the  portion  of  the  tibia  most  frequently  the  seat  of  these 
tumors.  They  vary  in  size  and  number,  but  are  usually  not  as  salient  as 
similar  swellings  of  other  bones.  The  radius  and  the  ulna  are  also  some- 
times attacked.  The  swellings  are  usually  near  the  joint,  the  wrist  more 
coiumonly  than  the  elbow. 

'  Maukiac  ;  Memoiresur  les  affections  syphilitiques  precoces  dusysteme  osseux. 
Paris.  1872. 


G78  AFFECTIONS    OF    THE    BONES,    ETC. 

These  tumors  often  attain  a  large  size  in  one  or  two  weeks.  The  pain 
which  is  always  present,  is  aggravated  by  pressure,  and  is  worse  at  night. 

The  lesion  is  undoubtedly  due  to  hypera;mia  of  the  periosteum  and  the 
formation  of  new  iibrous  tissue.  Gummy  infiltration  i)robably  does  not 
occur.  The  tumors  have  a  tendency  to  spontaneous  involution,  and  very 
rarely  break  down  and  form  ulcers.  If  left  to  themselves  they  become 
converted  into  bony  nodes,  but  they  yield  readily  to  proper  treatment.  In 
but  one  case,  a  tumor  of  the  sternum,  have  we  seen  neci'osis  take  place. 
The  ulcer,  which  resembled  a  gummatous  ulcer,  had  the  eroded  bone  for 
its  base  and  healed  slowly,  leaving  a  depressed  cicatrix.  Early  treatment 
prevents  deformity,  but  delay  may  result  in  superficial  atrophy  of  the 
bone. 

These  lesions  are  generally  accompanied  by  others  of  the  secondary 
stao-e ;  they  may  occur  even  before  the  disappearance  of  the  primary  sore.  • 
A  mild  form  of  hydrarthrosis  is  sometimes  induced  by  their  proximity  to 
a  joint. 

Treatment  should  be  both  local  and  internal.  Mercurial  ointment  well 
rubbed  in  twice  daily  and  kept  constantly  applied  to  the  parts,  is  the  best. 
If  it  cause  irritation  it  may  be  mixed  with  an  equal  quantity  of  oxide  of 
zinc  ointment.     Internally  the  mixed  treatment  is  required. 

Late  Osseous  Affections. 

These,  like  other  tertiary  lesions,  do  not  necessarily  occur  in  every  case 
of  syphilis,  even  if  left  to  itself  without  treatment ;  experience  shows  that 
in  the  great  majoi'ity  of  cases  tlie  disease  wears  itself  out  or  disappears 
under  treatment  during  the  secondary  stage.  The  causes  which  give  rise 
to  their  evolution  in  the  few,  while  the  many  escape,  are  but  little  under- 
stood. In  some  cases  we  feel  justified  in  ascribing  their  development  to  a 
strumous  diathesi's,  to  dissipated  habits,  to  unfavorable  hygienic  influences, 
or  to  absence  of  or  improper  treatment ;  but  the  cases  are  so  numerous  in 
which  none  of  tliese  causes  can  be  legitimately  evoked,  that  we  are  often 
obliged  to  find  a  refuge  for  our  ignorance  in  "  individual  idiosyncrasy." 

The  attempt,  which  has  repeatedly  been  made  by  different  authors  to 
attach  tertiary  lesions,  and  especially  lesions  of  the  bones,  to  the  mercury 
which  was  administered  during  the  earlier  stages  of  the  disease,  is  now 
shown  to  be  groundless  by  abundant  evidence.  The  investigations  of 
Mitscherlich,  at  Idria,  the  official  reports  of  physicians  at  Almaden,  and 
the  observations  of  Singer,  Pappenheim,  and  others,  among  gilders,  hat- 
makers,  and  men  employed  in  the  preparation  of  rabbit  skins,  all  prove 
that  persons  who  labor  with  mercury,  and  w'ho  are  constantly  exposed  to 
its  fumes,  are  by  no  means  subject  to  affections  of  the  bones.  Virchow,  who 
has  been  quoted  as  supporting  this  error,  strongly  repudiates  it  in  his  re- 
cent work  on  syphilis. 

In  the  time  of  their  development  affections  of  the  bones  sometimes  coin- 
cide with  late  secondary  lesions,  or  follow  the  latter  after  a  brief  interval. 
In  other  instances  they  occur  long  after  every  trace  of  the  disease  and 


INTLAMMATORY    FORM  —  OSTEO-PERIOSTITIS.  G79 

almost  its  very  recollection  has  faded  out,  and  they  are  then  especially  dan- 
gerous, because  many  years  of  health  may  lead  the  patient  to  overlook 
their  cause  and  to  neglect  them  until  such  time  as  irreparable  injury  has 
been  done. 

The  division  of  these  lesions  adopted  by  Lancereaux  appears  to  be  the 
best,  and  is  as  follows:  1.  Inflammatory  form.  2.  Gummy  form.  3. 
Dry  caries,  including  their  sequelae — exostoses,  caries,  and  necrosis. 

Inflammatory  Form.     Osteo-periostitis This  form  commences 

with  increased  vascularity  of  the  periosteum  and  subjacent  layer  of  bone, 
and  an  effusion  and  infiltration  either  of  fluid  or  of  a  yellowish  gelatinous 
substance  of  more  or  less  consistency.  The  deeper  texture  of  the  bone  is 
sometimes  attacked,  when  the  canaliculi  are  found  to  be  dilated  and  filled 
with  a  fiimilar  substance. 

The  bones  most  liable  to  be  thus  attacked  are  those  which  are  the  most 
superficial,  as  the  tibia,  ulna,  clavicle,  sternum,  and  cranium;  but  no  por- 
tion of  the  skeleton  can  be  said  to  be  exempt.  The  external  manifestation 
of  this  affection  consists  in  ill-defined  doughy  tumors  of  variable  size, 
shading  off  gradually  into  the  surrounding  tissues,  adherent  to  the  osseous 
structure  beneath,  but  independent  of  the  overlying  integument,  usually 
very  sensitive  to  pressure,  the  seat,  at  certain  hours  in  the  twenty-four,  of 
severe  pain,  and  bearing  the  common  name  of  nodes.  A  striking  pecu- 
liarity of  the  pains  produced  by  nodes  is  their  marked  nocturnal  character. 
They  are  generally  absent  or  are  scarcely  felt  during  the  day,  but  return 
at  night  with  great  severity  after  the  patient  retires  to  bed,  and  only  abate 
towards  morning.  This  nocturnal  exacerbation  is  attributed  to  the  warmth 
of  the  bed  by  Eicord,  who  states  that  in  bakers  and  others,  who  are  obliged 
by  their  occupation  to  turn  day  into  night,  the  pains  are  chiefly  diurnal. 
This  explanation,  however,  does  not  appear  to  hold  good  in  all  cases,  for 
in  some  they  return  at  a  certain  hour  in  the  evening,  whether  the  patient 
has  or  has  not  retired;  and,  in  a  few  instances,  they  are  equally  as  severe 
during  the  day  as  at  night.  These  pains  sometimes  exist  without  the 
appearance  of  any  organic  lesion,  and  in  such  instances  have  been  regarded 
as  the  direct  effect  of  syphilis,  but  it  is  extremely  probable  that  they  are 
always  dependent  upon  changes,  however  slight,  in  the  periosteum  or 
bone.  The  student  should  notice  the  diffei'ence  between  these  pains  and 
those  attending  early  secondary  symptoms — the  former  being  confined  to 
certain  regions,  usually  the  contiiniity  of  the  long  bones  and  those  portions 
of  the  skeleton  which  approach  nearest  the  surface,  and  nocturnal  in  their 
character,  while  the  latter  affect  by  preference  the  neighboriiood  of  the 
joints,  and  rapidly  change  their  locality  from  one  part  of  the  body  to 
another. 

In  the  majority  of  cases  of  nodes  the  serous  effusion  is  absoi'bed  under 
appropriate  trealment,  and  the  tumor  undergoes  resolution.  In  other 
cases  the  inflammation  is  more  acute;  the  skin  becomes  adherent  to  the 
tumor,  is  reddened  and  thinned;  degeneration  and  softening  take  place, 
and  an  opening  is  formed ;  the  ulcer  shows  little  or  no  tendency  to  extend, 


G'SO  AFFECTIONS    OF    THE    BONES,    ETC. 

but  a  su{)erficial  portion  of  the  bone,  to  a  limited  extent  usually  becomes 
necrosed  and  comes  away,  and  an  adherent  cicatrix  is  the  final  result. 

Exostosis In  other  cases  still,  the  eiiusion  is  more  plastic  and  organiz- 

able,  and  is  capable  of  being  transformed  into  bony  tissue,  constituting  an 
exostosis. 

Such  productions  are  often,  for  a  time  at  least,  movable  upon  the  bone 
beneath,  and  are  then  called  epipliysary  exostoses.  In  this  form  they  are 
due  rather  to  periostitis  than  to  ostitis.  They  are  generally  of  small  size, 
sometimes  thin  and  flat,  sometimes  hemispherical  or  pedunculated,  and  at 
times  annular.  "At  an  early  period  of  their  existence,  they  consist  of 
cellular  tissue,  containing  a  well-developed  network  of  vessels.  They 
acquire  greater  consistency  with  time,  and  finally  present  an  eburnated 
texture.  Arrived  at  this  point,  resolution  is  no  longer  possible ;  the  tumor 
i-emains  stationary,  and  treatment  has  no  other  effect  than  to  quiet  the 
osteocopic  pains.  If  resolution  be  attained  at  an  earlier  period,  their 
surface,  which  before  was  smooth,  becomes  irregular,  indicating  partial 
absorption.  Sometimes  this  absorption  continues  after  the  whole  of  the 
tumor  has  disappeared,  so  that  local  atrophy  of  the  bone  succeeds  the  ex- 
ostoSffS."^  In  other  instances,  syphilitic  exostosis  is  not  preceded  by  peri- 
ostitis, but  is  the  result  of  ostitis  terminating  in  hypertrophy  of  the  normal 
bony  tissue,  in  which  case  it  is  denominated  parenchymatous  exostosis. 

This  new  formation  assumes  two  characters :  that  of  cancellated  and 
that  of  compact  tissue.  If  made  up  of  layers  whicli  have  interspaces  or 
areola?  between  them,  they  receive  the  name  of  cellular  or  laminated  ex- 
ostoses; if,  however,  formed  of  compact  tissue,  and  accom[)anied  by  in- 
creased volume,  w^eight,  and  density  of  osseous  material,  they  are  called 
eburnated. 

An  exostosis  situated  externally  rarely  occasions  sufficient  inconvenience 
or  deformity  to  necessitate  its  removal  by  an  operation  unless  under  pecu- 
liar circumstances,  as  was  the  case  Avitli  a  violinist  from  whose  metacarpal 
bone  a  tumor  of  this  nature,  which  had  interfered  with  the  exercise  of  his 
profession,  was  removed  by  Ricord. 

But  exostoses  may  also  spring  from  the  internal  surface  of  the  cranial 
bones  and  give  rise  to  symptoms  of  the  most  serious  cliaracter,  as  convul- 
sions and  the  various  forms  of  paralysis.  The  frontal  bone  is  by  far  the 
most  frequently  affected  in  this  manner.  Lagneau,  in  his  work^  upon 
Svphilitic  Affections  of  the  Nervous  System,  has  been  able  to  collect  but 
three  cases  of  exostosis  springing  from  the  parietal,  and  one  from  the 
sphenoid  bone;  he  appears  to  have  met  with  none  in  the  occipital  or  tem- 
poral. These  intracranial  exostoses  vary  very  much  in  size.  Saltzman' 
reports  a  case  in  which  the  tumor  occupied  tlie  internal  surface  of  one  of 
the  parietal  bones  commencing  at  two  fingers'  breadth  from  the  sagittal 

'  N^LATox,  Pathologie  chirurgicale,  t.  ii,  p.  l(j. 

^  Maladies  syphilitiques  clu  systeme  iierveux,  jiar  Gustave  Lagneau  fils.  Paris, 
18G0,  p.  45. 

3  Acta  Pliys.  Med.  Acadoniia;  Ces.-Leop.  Carol.  Naturre  Curiosormn  P^ilieinerides, 
Noriinbergie,  1730,  t.  ii,  ^.  222,  obs.  99  (as  quoted  by  Lagneau  fils,  op.  cit.  p.  3G1). 


GUMMY    FORM — OSTEOMYELITIS.  G81 

suture  and  extending  to  the  coronal  suture  in  front  and  the  temporal 
below  ;  the  patient  died  with  symptoms  of  apoplexy.  Within  the  cranium^ 
of  Clermont-Ferrand,  deposited  in  the'Dupuytren  Museum,  are  two  exos- 
toses, one  of  which  is  as  large  as  an  orange.  In  general,  however,  these 
tumors  are  much  smaller,  and  often  multiple.  They  also  vary  in  density, 
some  presenting  a  hard,  eburnated  texture,  while  others  are  cellular. 
Most  of  them  spring  directly  from  the  surface  of  the  bone  (parenchyma- 
tous exostoses) ;  indeed,  the  existence  of  epiphysary  exostoses  within  the 
cranium  has  been  denied,  but  VidaP  gives  a  representation  of  a  specimen 
in  the  Dupuytren  Museum,  in  Avhich  the  tumor  is  separated  from  the 
normal  tissue  by  a  distinct  line  of  demarcation. 

Syphilitic  exostosis  of  the  vertebrae,  either  external  or  within  the  spinal 
canal,  is  rare ;  but  Lagneau^  has  adduced  several  instances  reported  by 
Cloquet  and  Berard,  Godelier,  Piorry,  and  Minich. 

Syphilitic  exostoses  may  generally  be  distinguished  from  similar  growths 
due  to  other  causes  by  the  nocturnal  pains  attending  them,  by  their  usu- 
ally occupying  the  continuity  of  the  more  superficial  bones,  by  their  hemi- 
spherical form,  and  by  the  fact  tliat  they  are  rarely  multiple  or  symmetri- 
cal on  opposite  sides  of  the  body. 

Gummy  Form.     Osteo^myei.itis The  deposit  of  syphilitic  tubercle 

in  the  osseous  tissues  most  frequently  takes  place  in  tlie  medullary  canal 
of  the  long  bones,  although  it  sometimes  occurs  in  the  periosteum  and  in 
the  substance  of  the  bone  itself,  giving  rise  to  one  of  the  most  painful  and 
obstinate  of  tertiary  lesions.  Ricord*  gives  two  fine  representations  of 
cases  of  this  description.  "  In  one,  the  two  radii  which  had  been  the  seat 
of  very  violent  osteocopic  pains  and  of  exostoses,  were  remarkably  hyper- 
trophied  in  their  inferior  portions.  At  an  inch  and  a  half  from  the  lower 
extremity  of  the  right  radius  there  was  such  a  considerable  enlargement 
as  to  lead  one  to  believe  in  an  old  fracture  which  had  united  badly;  but  on 
close  examination  it  was  evident  that  there  was  only  hypertrophy  with 
development  of  the  osseous  canaliculi ;  the  bone  was  here  redder,  and 
more  porous  than  anywhere  else ;  the  medullary  substance  was  hardened 
and  yellowish,  and  looked  like  rancid  lard.  The  left  radius  was  hyper- 
tropliied  in  a  similar  manner  and  to  a  much  greater  extent,  the  whole  of 
the  inferior  half  being  involved."  In  the  other  case  there  was  plastic 
infiltration  in  the  medullary  canals  of  both  bones  of  the  leg,  at  [)oints 
corresponding  to  exostoses  upon  the  surface. 

In  rarer  instances,  a  similar  deposit  of  a  whitish  or  yellowish  color,  and 
of  the  consistency  of  mucilage,  or  sometimes  firmer,  occurs  in  the  perios- 
teum external  to  the  bone  itself,  and  gives  rise  to  a  soft  fiuctuating  tumor, 
which,  like  the  gummata  of  the  cellular  tissue,  finally  softens  and  dis- 
charges its  contents  through  infiamniation  and  ulceration  of  the  overlying 

'  '  Figured  by  Vidal,  I'atliologie  cxtcTnc,  2(,'  edition,  t.  iii,  p.  Ill,  184G. 
2  Op.  cit.  t.  iii,  p.  116.  ^  Op.  cit.  p.  193. 

*  Iconograpliie,  I'l.  XXVIII  his  vt  XXXIX  bis. 


682 


AFFECTIONS    OF    THE    BOxVES,    ETC. 


skin ;  more  rarely  it  undergoes  calcareous  degeneration  and  leaves  a  pro- 
jecting mass.  This  degeneration  is  of  more  frequent  occurrence  in  this 
than  in  any  other  form  of  gummata. 


Gummata  of  the  head  aiul  face.     (After  Jullien.) 

This  exudation  may  also  affect  the  bones  of  the  head,  where  it  com- 
monly occupies  the  diploe,  separating  in  its  development  the  two  layers  of 
the  skull,  and  leading  to  their  ultimate  caries  or  necrosis,  and  frequently 
to  perforation  of  the  external  or  internal  table.  More  or  less  of  one  of 
these  tables  may  exfoliate,  leaving  the  diploe  and  opposite  layer  intact. 
In  a  case  observed  by  Dupuytren,^  two-thirds  of  the  internal  table  of  the 
skull  were  necrosed;  and  in  another,  reported  by  Petrequin,''  the  whole 
external  table  of  the  frontal  bone  exfoliated.  More  frequently,  although 
the  external  table  is  involved  to  the  greater  extent,  the  diploe  and  internal 
table  are  perforated  at  one  or  more  points,  laying  bare  the  dura  mater, 
which,  when  the  opening  is  large,  may  protrude  externally,  either  pre- 
serving its  normal  character,  or  assuming  a  highly  vascular  and  fungous 
apj)earance. 

In  the  case  of  a  woman  recently  under  my  care  at  Charity  Hospital, 
Blackwell's  Island,  I  removed  nearly  tlie  whole  of  tlie  frontal  bone,  which 
was  necrosed,  including  portions  of  both  supra-orbital  plates.     The  exposed 


'  Clinique  de  I'Hotel  Dieu  ;  Transactions  niedicales,  par  MM.  Foget  et  Sandkas, 
Paris,  1832,  t.  x,  p.  209  (quoted  by  Lagneau,  op.  cit.  p.  403). 
^  Gaz.  med  de  Paris,  1836,  t.  iv,  p.  643. 


DRY    CARIES.  683 

surface  of  the  cinra  mater  over  this  hirge  extent  of  surface  afterwards  put 
on  copious  granulations,  and  would  from  time  to  time  be  nearly  covered 
with  cicatricial  tissue,  when  the  process  of  repair  would  seem  to  flag,  and 
ulceration  again  set  in.  This  occurred  repeatedly,  and  the  patient  finally 
left  the  hospital  without  the  wound  being  firmly  closed. 

When  the  disease  affects  chiefly  the  internal  table  of  the  skull,  the  in- 
flammatory products  and  portions  of  necrosed  bone  sometimes  find  exit 
through  perforation  of  the  external  parts  ;  or,  in  other  instances,  they  accu- 
mulate between  the  bone  and  dura  mater,  cause  compression  of  the  brain, 
or  give  rise  to  encephalo-meningitis  and  disorganization  of  the  cerebral 
substance.  Moreover,  in  nearly  every  case  of  syphilitic  disease  oi"  the 
cranial  bones,  the  dura  mater,  upon  its  internal  or  cerebral  aspect,  pre- 
sents thin  layers  of  fibrinous  or  hemorrhagic  deposit,  which  are  easily  de- 
tached from  the  surface.^ 

Virchow^  states  that  necrosis  produced  by  syphilis  may  be  distinguished 
from  that  due  to  other  causes  by  the  following  symptoms  :  "  In  syphilitic 
necroses,  the  surface  of  the  sequestrum  is  pierced  with  large  holes,  wdiich 
unite  internally  and  lead  to  the  suspicion  that  they  have  been  due  to  a 
deposition  of  gummy  material ;  the  surrounding  tissue,  whether  necrosed 
or  not,  is  often  dense  and  eburnated,  presenting  a  strong  contrast  to  the 
above." 

Follin  and  Lancereaux  both  remark  that  the  specimens  of  syphilitic  ne- 
crosis of  the  cranial  bones  deposited  in  the  Dupuytren  Museum  of  Paris, 
exhibit  an  outline  similar  to  the  semicircles  of  certain  annular  syphilides. 
This  is  a  curious  fiict  as  showing  the  tendency  of  syphilitic  symptoms  to 
assume  a  circular  form  even  in  deep  lesions,  but  no  great  importance  can 
be  attached  to  it  in  the  diagnosis  of  any  individual  case. 

It  is  hardly  necessary  to  add  that  other  bones  than  the  cranial  are  also 
subject  to  caries  and  necrosis  under  the  influence  of  syphilis  ;  in  practice, 
however,  we  find  these  lesions  mainly  in  the  bones  of  the  head,  the  nose, 
the  hard  palate,  and  the  alveolar  process  of  the  upper  jaw,  where  unfortu- 
nately they  are  most  likely  to  result  in  deformity  of  feature  or  voice,  only 
partially  remediable  by  plastic  or  dental  surgery. 

Dry  Caries Underthehead  of  "  dry  caries" or"  inflammatory  atrophy 

of  the  bone,"  Virchow  has  described  an  affection  which  he  believes  to  be 
peculiar  to  syphilis,  and  the  chief  characteristic  of  which  is  the  entire  ab- 
sence of  suppuration.  With  the  exception  of  a  single  instance  in  which 
the  sternum  was  involved,  all  his  observations  relate  to  the  bones  of  the 
head,  and  chiefly  to  the  frontal  and  parietal  bones  which  were  attacked 
either  in  their  external  or  internal  tables,  or  in  both  conjointly. 

The  changes  observed  consist  in  atrophy  or  rarefaction  at  certain  points 
upon  the  external  or  internal  surface  of  the  bone,  with  hypertrophy  or 
condensation  of  the  osseous  tissue  surrounding  them.  The  rarefaction 
commences  with  enlargement  of  the  vascular  canals  of  the  bone.     0[)enings 

'  Virchow,  Syphilis  constitutionelle,  p.  50. 
2  Op.  cit.  p.  49. 


G84  AFFECTIONS    OF    THE    BONES,    ETC. 

are  found  which  are  the  extremities  of  the  Haversian  canals  of  the  cortical 
substance,  and  towards  these  converge  radiated  furrows  which  are  formed 
by  the  canals  parallel  to  the  surface.  Thus  small  star  or  funnel  shaped 
depressions  are  formed,  which  gradually  increase  somewhat  in  size.  When 
existing  on  both  the  external  and  internal  aspect  of  the  bone,  they  some- 
times though  rarely  correspond  to  each  other,  and  may  produce  complete 
perforation. 

At  tlie  same  time  osseous  tissue  of  new  formation  is  being  deposited 
at  the  periphery  of  these  points  of  atrophy ;  it  is  first  seen  as  a  thin,  soft, 
and  very  vascular  pellicle,  which  rapidly  ossifies,  and  unites  with  the  origi- 
nal bony  structure,  constituting  a  simple  hyperostosis  or  periostosis,  and 
not  an  exostosis.  A  similar  hypertro})hy  also  occurs  around  the  extremi- 
ties of  the  funnel-shaped  depressions,  whereby  the  medullary  cavities  of 
the  diploe  are  obliterated,  and  sclerosis  of  the  whole  affected  portion  is  pro- 
duced. Unlike  ordinary  caries,  this  affection  never  exhibits  the  slightest 
trace  of  pus. 

In  several  instances,  Virchow  has  found  the  depressions  above  desci'ibed 
filled  with  a  conical-shaped  mass  of  tissue  of  new  formation,  which  he  re- 
gards as  syphilitic  tubercle  originating  partly  in  the  pericranium  (upon 
the  external  surface)  or  the  external  layer  of  the  dura  mater  (on  the  in- 
ternal surface)  and  in  the  bone  itself;  and  he  arrives  at  the  conclusion  that 
this  form  of  atrophy  is  "  intimately  allied  to  the  formation  of  gummata,  and 
that  the  sensible  depression  of  the  cortical  layer  of  the  bone  only  occurs 
after  the  absorption  of  the  gum,  which  takes  place  more  readily  upon  the 
external  than  upon  the  internal  surface  of  the  cranium."^ 

Syphilitic  Cicatrices  in  the  Bones It  remains  for  us  to  inquire 

Aviiether  such  syphilitic  lesions  as  involve  a  loss  of  substance  of  bony  tissue 
leave  behind  them  any  peculiarity  in  the  cicatrix,  which  may  enable  us, 
if  not  always  to  determine,  at  least  strongly  to  suspect,  their  nature.  Ob- 
servation answers — yes. 

Under  other  circumstances,  as,  for  instance,  after  the  removal  of  a  por- 
tion of  one  of  the  cranial  bones  by  trephining,  the  opening  is,  to  be  sure, 
never  entirely  filled  again  by  a  new  formation  of  osseous  tissue,  yet  there 
is  an  attempt  in  tliis  direction,  since  we  find  the  hole  contracted  by  means 
of  a  bony  outgrowth  from  its  edges.  Now  in  the  loss  of  substance  from 
syphilitic  necrosis,  it  is  entirely  exceptional  to  find  anything  of  the  kind 
take  place. 

'■'■A  syj)hilitic  cicatrix  of  the  hones  is  distinfjuished  hy  a  want  of  pro- 
ductivity at  the  centre,  and  hy  an  excess  of  productivity  at  the  peripliery." 
In  a  word,  we  have  here  on  a  larger  scale  what  we  have  just  seen  to  ob- 
tain in  the  depressions  of  dry  caries  or  inflammatory  atrophy.  Still  sup- 
posing one  of  the  cranial  bones  to  be  the  seat  of  the  lesion,  "the  dura 
mater  becomes  thickened  from  the  outset,  and  when  the  necrosed  portion 
has  been  eliminated,  a  cicatrix  is  produced,  the  edges  of  which  are  formed 

'  French  translation,  p.  49. 


TREATMENT.  685 

by  the  union  of  the  skin  and  the  soft  parts  covering  the  cranium  with  the 
bones  and  the  dura  mater;  towards  the  centre  is  found  a  callous,  uniform, 
whitish  mass,  which  is  very  compact  and  pooi-ly  supplied  with  vessels,  and 
which  gradually  thickens  and  contracts ;  the  natural  arching  of  the  cranium 
finally  disappears  at  this  part,  and  is  replaced  by  a  depression  of  the  whole 
cicatricial  surface. 

"The  peripheric  portions  of  the  bones  undergo  quite  a  different  change; 
they  are  affected  with  sclerosis,  often  in  combination  with  considerable 
hyperostosis.  The  medullary  cavities  are  gradually  filled  Avith  an  osseous 
substance;  the  bone  becomes  hard,  thick,  heavy,  and  at  last  quite  ebur- 
nated,  and  on  its  surface  there  are  smooth  prominences,  either  aggregated 
or  mammillated;  but  there  is  this  decided  peculiarity  about  these  new 
formations,  viz.,  that  they  form  slowly  and  in  small  quantity,  and  that  the 
periosteal  collections  are  totally  unlike  the  porous,  voluminous  masses 
resembling  pumice-stone,  which  are  so  abundantly  produced  in  mercurial 
or  phosphoric  necrosis  of  the  maxillary  bones,  and  which  are  also  met 
with,  although  to  a  less  extent,  in  all  other  forms  of  necrosis."^  These 
changes  therefore  closely  resemble  those  occurring  in  inflammatory  atrophy 
without  suppuration  or  necrosis,  and  the  diagnosis  must  sometimes  be  made 
from  the  history  of  the  case  and  an  examination  of  the  surrounding  soft  parts. 

If  any  portion  of  a  bone  has  been  entirely  destroyed,  as,  for  instance, 
the  vomer  or  a  part  of  the  hard  palate,  nature  does  not  attempt  to  supply 
the  deficiency,  at  least  with  osseous  tissue. 

Several  authors  have  mentioned  extreme  fragility  of  the  bones  in  general 
as  one  of  the  effects  of  syphilis.  A  patient  who  was  under  my  care  a  few 
years  since  for  syphilitic  necrosis  of  the  bones  of  the  head,  fractured  his 
thigh  while  simply  turning  in  bed.  Deatli  ensued  from  exhaustion  in  the 
course  of  a  few  weeks,  but  no  opportunity  was  offered  for  a  post-mortem 
examination.  It  is  not  probable,  however,  in  this  and  other  similar  cases 
that  Iiave  been  reported,  that  a  condition  of  mollities  ossium  exists,  but 
rather  that  the  bones  at  the  point  of  fracture  have  had  their  integMty  im- 
paired in  one  of  the  modes  previously  mentioned. 

Treatment. — Most  of  the  above  affections  of  the  osseous  tissues  yield 
with  great  facility  to  the  treatment  appropriate  for  tertiary  syphilis.  Osteo- 
copic  pains,  and  nodes  especially,  often  disappear  in  an  almost  marvellous 
manner  under  the  free  administration  of  iodide  of  potassium,  but  they  are 
very  apt  to  return.  As  I  have  previously  stated,  I  believe  the  greatest 
protection  against  a  relapse  is  the  combined  use  of  mercury  in  the  form 
of  inunction. 

In  most  of  the  supposed  desperate  cases  of  syphilitic  disease  of  the  bones 
that  I  see  in  consultation,  the  attending  surgeon  has  been  trifling  with 
insignificant  and  insufficient  doses  of  his  remedies — giving  for  a  while 
some  ten  or  fifteen  grains  of  the  iodide  of  potassium  in  the  twenty-four 
hours,  and,  this  failing,  resorting  to  a  sixteenth  or  the  twelfth  of  a  grain 

'  ViKciiow,  oj).  cit.  p.  62. 


686  AFFECTIONS    OF    THE    BONES,    ETC. 

of  corrosive  sublimate,  three  times  a  day,  until  his  patient  had  such  a 
diarrh(jca  and  was  so  run  down  that  he  was  obliged  to  desist,  and  was  now 
at  tlie  end  of  his  resources.  At  the  suggestion  of  forty,  sixty,  or  a  hundred 
or  more  grains  of  the  iodide  per  diem,  and  tlie  nightly  use  of  a  draclim  of 
mercurial  ointment  by  inunction,  it  is  often  objected:  "Why,  I  have  been 
giving  just  these  remedies" — as  if  it  were  sufficient  to  have  the  proper  tools, 
and  it  made  no  difference  how  they  w^ere  used ! 

In  the  great  majority  of  cases  of  osteocopic  pains,  ostitis,  nodes,  etc.,  I 
prefer  to  abstain  entirely  from  local  treatment ;  the  small  benefit  that  it 
can  afford  is  more  than  counterbalanced  by  its  inconvenience  and  its  divert- 
ing the  patient's  mind  from  his  chief  source  of  relief.  If,  however,  any 
local  treatment  be  adopted,  the  best  is  the  repeated  application  of  blisters, 
which  may  be  dressed  with  an  ointment  containing  morphine. 

Many  practitioners  are  altogether  too  prone  to  plunge  a  lancet  into  the 
tumor.  Resolution  may  often  be  obtained  even  after  fluctuation  is  evident, 
and  when  an  incision  and  consequent  exposure  of  the  bone  woidd  be  fol- 
loAved  by  caries  or  necrosis  of  its  superficial  layer.  This  treatment  should 
be  left  as  a  last  resource  after  other  means  have  failed,  in  which  case  it  is 
probable  that  there  is  some  sequestrum  that  can  only  be  got  rid  of  in  this 
manner. 

"  When  suppuration  or  caries  occurs,  especially  of  the  bones  of  the  face 
which  are  so  often  necrosed  in  these  cases,  we  should  never  fail  to  remove 
them  as  soon  as  they  can  be  separated  from  the  sound  parts.  We  must 
recollect  that  caries  engenders  caries ;  that  when  the  organic  tissue  of  a 
bone  has  been  destroyed  by  suppuration  or  has  lost  its  vitality,  it  cannot  be 
regenerated  by  any  constitutional  or  local  treatment  whatsoever ;  and  that 
its  debris  should  never  be  left  to  spontaneous  evolution,  since  they  are  for- 
eign bodies,  maintaining  and  extending  suppuration,  which,  by  involving 
important  parts,  may  occasion  the  most  serious  symptoms,  or  even  result  in 
death."! 

Affections  op  the  Caktilages. 

Syphilis  may  attack  the  cartilages  as  well  as  tlie  bones.  The  cartilages 
of  the  larynx  are  a  favorite  seat  for  tertiary  syi)hilis,  which  often  results  in 
necrosis,  and  the  sequestra  are  sometimes  exi)elled  in  the  attempts  at  ex- 
pectoration. 

Lancereaux  reports  a  case  in  which  the  purulent  collection  in  this 
region  was  the  origin  of  ])y!emia  and  metastatic  abscesses  ;  severe  chills 
suddeidy  occurred,  and  the  patient  died  in  a  week  ;  the  autopsy  confirmed 
the  diagnosis. 

Bouisson  speaks  of  a  case  of  perichondritis  of  the  costal  cartilages  in 
a  man  who  also  had  a  sypliilitic  tumor  in  the  pectoralis  major  muscle- 
(Lancereaux.) 

We  also  have  seen  swellings  of  the  costal  cartilages  developed  simulta- 
neously with  tumors  of  the  sternum.     Syphilis  may  therefore  cause  gummy 

'  RicoRD,  Notes  to  Hunter,  2d  Am.  ed.,  1859,  p.  507. 


AFFECTIONS    OF    THE    JOINTS.  687 

infiltration  of  cartilage  as  well  as  of  bone.  ^Vheu  the  joints  are  the  seat  of 
these  syphilitic  changes  the  cartilages  may  be  eroded  and  crepitation 
may  be  heard.  This  condition  is  probably  merely  a  result  of  impaired 
nutrition. 

Affections  of  the  Joints. 

The  joints  are  frequently  affected  by  syphilis  in  botli  the  secondary  and 
tertiary  stages.  In  some  instances  the  morbid  process  begins  in  the  joint 
structures,  and  in  others  inflammation  of  the  articular  ends  of  the  bones  and 
of  the  large  tendons  inserted  near  the  joints  involves  the  latter  secondarily. 

Arthralgia. — In  the  secondary  stage,  and  frequently  as  early  as  the 
appearance  of  the  first  general  manifestations,  one  or  more  joints  may  be 
the  seat  of  pain.  Externally  there  is  no  redness  of  the  skin  nor  subcuta- 
neous inflammation,  no  swelling  from  effusion  and  no  elevation  of  the 
temperature  of  the  parts ;  in  fact  very  often  the  only  evidence  of  disease 
is  the  pain.  In  some  instances  pressure  causes  no  i)ain,  but  movement  of 
the  joint  does,  and  there  is  more  or  less  stifthess  and  inability  to  move  the 
joint.  The  pain  is  slight  or  of  a  dull  character  during  the  day,  but  is  often 
attended  with  marked  exacerbation  at  night.  After  considerable  motion 
the  stiffness  and  pain  may  disappear  to  return  at  night  when  the  joint  is 
in  a  state  of  repose.  In  other  instances,  however,  the  suffering  of  the 
patient  is  very  great,  preventing  sleep  imtil  late  in  the  night  or  towards  morn- 
ing. Not  unfrequently,  coincidently  with  the  joint  affection,  there  is 
marked  fever  of  the  remittent  type,  and  patients  may  also  suffer  from 
rheumatoid  pains  in  the  muscles,  neuralgias  and  periosteal  pains. 

This  affection  is  very  uncertain  in  its  duration,  being  sometimes  very 
ephemeral  and  at  other  times  very  persistent. 

It  is  readily  amenable  to  treatment  when  this  is  commenced  early,  but 
otherwise,  it  is  obstinate  and  troublesome.  It  most  commonly  attacks  the 
larger  joints  either  symmetrically  or  the  opposite,  and  the  joints  of  the 
hands  and  feet  are  not  infrecpiently  involved.  The  knee-joint  is  most  fre 
quently  attacked,  but  those  of  the  shoulder,  elbow,  wrist,  and  ankle  are 
also  oi"ten  affected.  In  general  only  two  or  three  of  tiie  larger  joints  are 
involved  at  onc^,  and  tiiere  is  not,  as  in  articular  rheumatism,  a  tendency 
to  metastasis  from  one  joint  to  another.  Wlien  the  affection  involves  the 
smaller  joints,  as  those  of  the  piialanges  or  carpal  bones,  several  of  them 
are  generally  attacked  simultaneously,  and  the  earlier  it  occurs  in  the 
course  of  syphilis,  so  is  the  tendency  to  its  symmetrical  d<!velopment  greater. 
"While  in  most  cases  there  is  no  evidence  of  any  abnormal  condition  of  the 
articular  surfaces,  in  others  crei)itation  may  be  heard,  indicating  some  im- 
pairment of  nutrition  of  the  oi)[)Osed  surfaces.  Tiie  lesion,  which  cannot 
be  positively  determined,  is  probably  a  low  grade  of  hyperiemia  of  the  syno- 
vial membrane  and  fibrous  tissues. 

Tiiis  aflection  is  caUed  by  Fournicr  both  arthralgia  and  jtscudo-rhcinna- 
tism,  and  by  Yaffier  sypliilitic  rheumatism.      The  diagnosis  between  it  and 


G88  AFFECTIONS    OF    THE    BONES,    ETC. 

ordinary  rlieumatism  is  to  be  derived  chieHy  from  the  history  of  the  case 
and  the  concomitant  lesions  and  symptoms.  The  course  of  this  aflfection 
is  very  subacute  ;  there  is  not  the  same  tendency  for  so  many  of  the  joints 
to  be  affected  as  in  rheumatism,  and  there  is  absence  of  the  systemic  con- 
dition and  of  the  perspiration  peculiar  to  the  latter  disease.  The  appro- 
priate treatment  is  by  mercury  if  the  affection  occurs  at  an  early  stage  of 
syphilis,  and  by  the  mixed  treatment  if  in  the  late  stage. 

Synovitis. — There  are  two  forms  of  synovitis  occurring  during  the 
course  of  syphilis  ;  the  one  simply  a  chronic  effusion  into  the  joint  with- 
out any  appreciable  change  therein  ;  tlie  other  an  affection,  in  which  there 
is,  besides  the  effusion,  a  thickening  of  tlie  synovial  membrane. 

Synovitis  of  the  Early  Stage. — This  begins  slowly  and  painlessly.  Tlie 
patient  (experiences  sliglit  stiffness  in  the  joint  which  is  found  to  be  swollen. 
On  examination,  the  usual  symptoms  of  effusion  are  found,  which  vary 
according  to  the  joint  attacked.  The  skin  covering  the  joint  is  not  changed. 
Firm  pressure  may  cause  slight  pain,  and  dull  pain  may  often  be  felt  at 
night,  but  the  articular  surfaces  may  be  crowded  together  with  impunity. 
The  amount  of  effused  fluid  varies ;  in  some  cases  it  is  very  sliglit,  in 
others  copious.  A  peculiar  feature  of  this  affection  is  the  intermittent 
character  of  the  effusion.  For  example,  a  patient  may  have  complained 
of  a  moderate  effusion  which  seemed  to  wholly  pass  away  ;  after  a  longer 
or  siiorter  period  it  returns,  and  reaches  a  certain  stage  where  it  remains 
for  a  time;  then  the  swelling  increases  ;  afterwards  it  decreases  very  per- 
ceptibly, and  again  increases  to  marked  proportions.  During  this  whole 
period  the  patient  has  suffered  little  inconvenience,  except  a  slightly  pain- 
ful stiffness  of  the  joint  in  the  morning,  which  passes  away  in  an  hour  or 
two,  and  perhaps  a  slight  pain  at  niglit.  Not  infrequently  such  patients 
also  suffer  from  periosteal  pain  in  the  course  of  the  long  bones,  or  from 
nocturnal  neuralgia.  The  effusion  may  remain  for  a  long  or  short  period. 
In  some,  particularly  those  who  are  subjected  to  treatment,  it  passes  slowly 
away,  and  the  joint  is  apparently  left  in  its  normal  condition.  In  other 
cases,  the  affection  is  chronic  and  persistent,  and  the  effusion  disap[)ears 
very  slowly.  In  these  cases  we  usually  find  the  whole  joint  somewhat 
enlarged  and  indurated,  and  sul)ject  to  frequent  small  effusions.  There  is 
no  tendency  to  suppuration  or  destruction  of  the  joint. 

Tlie  diagnosis  of  this  affection  can  be  generally  made  out  without  diffi- 
culty. The  history  of  the  case,  and  the  slow,  painless,  intermittent,  and 
subacute  cliaracter  of  the  effusion,  establish  its  distinct  nature  from  the 
synovitis  of  rheumatism  or  of  gonorrluca. 

Synovitis  of  the  Late  Stage The  synovitis  which  occurs  late  in  the 

secondary  and  during  tlie  tertiary  stage,  is  also  markedly  subacute.  It  is 
attended  with  the  same  symptoms,  and  is  mainly  distinguishable  from  that 
of  the  earlier  period  by  appreciable  lesions  of  the  joint  structures.  The 
attention  of  the  patient  is  called  to  the  affection  by  slight  pain  and  impair- 
ment of  motion,  and  the  joint  is  then  found  somewhat  enhirged.  The 
effusion  into  its  cavity  takes  place  slowly  and  perhaps  intermittingly,  so 


SYNOVITIS.  689 

that  in  many  cases  several  months  elapse  before  the  joint  is  very  decidedly 
enlarged.  When  the  affection  is  fully  developed  we  find  evidence  of 
intra-articular  effusion  and  general  thickening  of  the  fibrous  coverings  and 
of  the  synovial  membrane.  The  affection  has  been  called  by  Richet,^ 
who  first  described  it,  "  syphilitic  white  swelling,"  and  Avas  said  by  him 
to  be  due  to  gummy  infiltration  into  the  sub-synovial  connective  tissue 
and  into  the  reflections  of  the  membrane  which  lined  the  joints.  This 
view  was  not  generally  received,  but  the  more  recent  post-mortem  obser- 
vations of  Lancereaux^  have  confirmed  them.  The  latter  in  his  excellent 
text-book  gives  a  coloi-ed  lithograph  of  the  appearances  presented  by  a 
joint  thus  diseased,  and  clearly  shows  masses  of  gummy  material  in  the 
sub-synovial  tissues. 

It  is  probable  that  this  is  the  chief  focus  of  the  lesion,  but  in  some 
cases,  there  is  a  coexisting  hyperplasia  of  the  fibrous  structures  of  the 
parts.  This  affection  may  remain  in  an  indolent  condition  for  years  with- 
out undergoing  any  further  changes.  There  is  little  tendency  to  complete 
anchylosis,  though  quite  frequently  there  is  more  or  less  erosion  of  the 
articular  cartilages,  as  shown  by  the  crepitation  on  motion.  We  seldom 
find  sinuses  near  the  joints,  and  the  stationary  character  of  the  affection 
is  in  marked  contrast  to  the  tendency  to  degeneration,  which  is  such  a 
prominent  feature  of  the  strumous  affections  of  these  parts.  The  knee- 
joint  is  the  one  most  commonly  attacked. 

The  prognosis  of  this  affection  is  rather  more  serious  than  that  of  the 
earlier  form.  If  it  is  submitted  to  treatment  early,  it  is  in  general  curable, 
but  if  it  is  neglected,  permanent  thickening  occurs,  and  consequently 
more  or  less  impairment  of  motion. 

The  constitutional  treatment  consists  in  the  administration  of  the  iodide 
of  potassium  and  of  mercury.  Locally,  frictions  with  a  mild  mercurial 
ointment,  and  compression  of  the  joint  by  means  of  strips  of  mercurial 
plaster  ai-e  very  efficacious.  In  the  most  rebellious  cases  it  is  necessary 
to  render  the  joint  thoroughly  immobile  by  means  of  the  starch,  plaster  of 
Paris,  or,  preferably,  the  silicate  of  soda  (so-called  "  glass")  dressing. 

In  some  cases  in  which  there  is  a  sypliilitic  affection  of  the  tendons 
inserted  near  a  joint,  there  is  a  coincident  effusion  into  the  cavity  of  the 
latter.  This  occurs  slowly  and  painlessly  and  disappears  on  the  subsidence 
of  tlie  disease  of  the  tendon. 

Accompanying  the  osteo-chondritis  of  children,  in  which  there  is  inflam- 
mation of  the  diaphyso-epiphyseal  junction,  there  is  also,  in  some  instances, 
effusion  into  the  cavity  of  the  joint  at  the  end  of  the  affected  epiphysis. 
This  affection,  which  is  described  in  the  chapter  on  hereditary  syphilis, 
occurs  most  commonly  within  the  first  year,  but  in  some  cases  even  as 
late  as  the  twelfth  year.  In  such  cases  we  find  a  general  enlargement  of 
the  epiphysis  and  swelling  of  the  joints. 

•  Do  la  tumeur  blanche  ;  Memoires  de  I'Acad.  de.  m6d.,  Paris,  t.  xvii,  1853, 
pp.  249,  250,  251,  25^. 

2  Traite  historique  et  pratique  de  la  syphilis,  Paris,  1873. 

44 


690  AFFECTIONS    OF    THE    EYES. 


CHAPTER   XXIV. 

AFFECTIONS   OF   THE   EYES. 

A  LARGE  number  of  tissues  enter  into  the  composition  of  the  orbit  and 
its  contents,  and  syphilitic  affections  of  this  region  are  correspondingly 
numerous ;  but  a  minute  description  of  all  of  them  would  be  inconsistent 
with  the  limits  of  this  work ;  and  I  shall  therefore  merely  allude  to  several 
of  them  and  dwell  chiefly  upon  those  which  are  the  most  common  and  most 
likely  to  fall  under  the  care  of  the  general  practitioner. 

Affections  of  the  Bones  of  the  Orbit. 

These  may  show  themselves  either  as  periostitis,  caries,  or  necrosis. 
They  produce  the  same  genei'al  symptoms  and  appearance  as  in  other  parts 
of  the  body,  but,  from  the  very  seat  of  the  trouble  and  the  proximity  of 
the  inflammatory  action  to  the  delicate  and  complex  organ  of  the  eye  on 
the  one  hand  and  the  sensorium  on  the  other,  the  symptoms  are  apt  to  be 
graver  and  the  results  more  disastrous  here  than  elsewhere,  except  within 
the  cavity  of  the  cranium  itself. 

The  inflammation  is  very  liable  to  be  propagated  from  the  bony  walls  to 
the  contents  of  the  orbit  and  there  give  rise  either  to  a  superficial  or  deep- 
seated  cellulitis,  which,  if  unchecked,  may  result  in  the  formation  of  an 
abscess,  and  this,  in  its  turn,  may  either  seriously  threaten  the  integrity  o^* 
the  eye  or  cause  its  total  destruction.  Again,  sinuses  may  be  found  in 
different  directions  in  the  lids  or  their  surroundings,  through  which  the 
products  of  inflammation  may  be  discharged  for  an  almost  indefinite  period 
accompanied  by  ulceration  and  contraction  of  the  soft  parts,  with  eversion 
or  displacement  of  the  lids. 

The  favorite  seat  of  these  troubles  is  the  inner  portion  of  the  orbital  plate 
of  the  frontal  bone,  the  orbital  border,  superior  and  inferior,  and  the  os 
unguis,  in  which  latter  they  often  lead  to  troubles  in  the  lachrymal  pas- 
sages. 

The  results  of  orbital  cellulitis  may  be  the  same  here  as  in  the  idiopathic 
form  and  the  surgeon  must  be  prepared,  in  case  a  deep-seated  abscess 
forms,  to  evacuate  this  with  a  bold  free  incision  into  the  orbit  in  order  to 
save  the  eye,  or  it  may  be  the  life  of  the  patient. 

The  constitutional  disturbances  in  these  affections  of  the  bones,  espe- 
cially when  of  a  chronic  form,  are  sometimes  very  great,  and  the  patient 
often  becomes  reduced  in  a  marked  degree  through  pain  and  general  ner- 
vous prostration,  so  that  the  attpuding  physician  is  often  fearful  of  subjecting 


AFFECTIONS    OF    THE    BONES    OF    THE    ORBIT.  091 

liim  to  a  rigorous  course  of"  specific  treatment.  This  I  am  convinced  is  a 
mistake,  for  there  is  no  occasion  where  the  good  effects  of  a  vigorous  anti- 
syphilitic  course  is  more  marked  than  here,  as  well  in  regard  to  mercury 
as  to  iodide  of  potassium.  Very  large  doses  of  this  latter  drug  (5j)  two 
or  three  times  a  day  are  indeed  often  the  only  thing  which  seems  to  effect 
a  change  for  the  better. 

Syphilitic  nodes  may  be  met  with  upon  either  of  the  four  walls  of  the 
orbit.  They  are  most  frequent  near  the  anterior  opening  of  the  socket, 
but  may  occur  at  a  greater  or  less  depth  within  its  cavity  and  cause  pro- 
trusion of  the  eyeball  and  loss  of  vision  consequent  upon  stretching  of  the 
optic  nerve.     The  following  cases  are  reported  by  Mr.  Poland — ^ 

Case  1.  John  M ,  a3t.  41,  a  large,  bony,  well-developed  man,  became 

an  out-patient  at  MoorHelds,  suffering  from  an  extensive  swelling  of  the 
bone  at  the  upper  part  of  the  orbit,  encroaching  upon  the  eyeball  so  as  to 
displace  it  downwards  and  forwards.  The  history  of  the  case,  as  well  as 
the  present  marks  of  old  mischief,  at  once  indicated  the  nature  of  the 
growth. 

From  his  statement,  it  appeared  that  about  ten  years  ago  he  had  unde- 
niable syphilitic  inoculation,  hardened  chancre  and  a  non-suppurating  bubo, 
followed  by  secondary  symptoms  of  a  rather  protracted  form.  He  under- 
went mercurial  treatment,  both  internally  and  by  ointment,  and  with 
benefit ;  ultimately  he  became  free  from  all  symptoms,  and  since  that  time 
at  intervals  he  lias  had  occasional  attacks  of  rheumatism,  which  have  been 
relieved  by  iodide  of  potassium,  and  on  more  than  one  occasion  he  has  had 
nodes  on  the  tibia,  which  were  relieved  by  blisters.  The  present  swelling 
on  the  frontal  bone  had  been  in  existence  for  nearly  six  weeks,  and,  within 
the  last  few  days,  had  increased  most  rapidly  in  size  ;  it  was  perfectly  firm 
and  hard,  but  very  tender  and  painful,  and  seemed  to  extend  towards  tlie 
orbit,  instea<l  of  taking  the  usual  course  over  the  forehead,  and  had  already 
encroached  upon  the  eyeball,  slightly  displacing  it  downwards  and  forwards. 
There  were  no  cerebral  symptoms  whatever. 

The  man  was  ordered  to  take  three  grains  of  the  iodide  of  potassium 
three  times  a  day,  and  to  rub  an  ointment  of  the  same  on  the  swelling 
morning  and  night.  By  j)ersevering  with  this  treatment  for  three  months 
the  swelling  entirely  disap[)eared. 

Case  2.  Tiie  second  case  was  that  of  a  woman  nearly  six  feet  in  height, 
and  of  immense  bony  development,  who  came  under  Mr.  Poland's  care  at 
Moorfields,  having  a  large  node  growing  from  the  inner  wall  of  the  orbit  ; 
it  was  perfectly  solid  to  the  touch,  but  j)ushed  the  eye  outwards  and  for- 
wards, i\tu\  had  caused  tension  of  tiie  optic  nerve,  so  that  there  was  loss  of 
sight,  dilated  fixed  pupil,  and  perfect  immoliility  of  the  eye.  She  soon 
afterwards  had  severe  cerel)ral  symptoms,  and  died  suddenly  in  a  comatose 
condition.     There  was  no  examination  of  the  body. 

I  never  met  with  exoi)htlia]mos  dependent  upon  this  cause  during  many 
years'  connection  with  the  N.  Y.  Eye  Infirmary. 

Real  exostoses  may  form  in  the  bones  of  the  orbit  as  the  result  of  sy- 
phtlis. 

'  On  Protrusion  of  tho  Kyeball,  Ophtliahiiic  Hospital  I^oports,  vol.  ii,  p,  223. 


692  affections  of  the  eyes. 

Affections  of  the  Lachrymal  Passages. 

Sj'philis  not  unfrequently  giv'es  rise  to  clianges  in  the  lachrymal  passages, 
causing  obstruction  to  the  flow  of  tears,  epiphora  and  lachrymal  abscess  and 
fistula.  Since  these  passages  are  not  exposed  to  direct  observation,  the 
exact  nature  of  the  changes  in  their  walls  is  not  always  appai-ent.  In  a  few 
instances,  the  disease  appears  to  be  confined  to  the  mucous  membrane  and 
submucous  tissue,  and  to  consist  in  catarrhal  inflammation,  consequent 
oedema,  and  ulceration  ;  in  the  majority  of  cases,  however,  it  commences 
in  the  bony  wall  or  periosteum,  and  the  mucous  membrane  is  affected 
secondarily ;  changes  which  correspond  to  those  met  with  in  other  mucous 
membranes  contiguous  to  bony  tissue.  The  character  of  the  coexistent 
syphilitic  symptoms  may  afford  some  idea  of  the  changes  in  the  tear  passages, 
■which,  however,  can  only  be  accurately  determined  by  direct  exploration. 

The  symptoms  are  sufficiently  obvious.  The  tears  meeting  with  obstruc- 
tion to  their  transit  through  the  lachrymal  passages,  collect  upon  the  con- 
junctival surface ;  if  profuse,  they  flow  over  upon  the  cheek,  especially  when 
the  patient  is  exposed  to  the  wind,  and  the  eye  is  evidently  more  moist 
than  its  fellow,  whence  the  name  "  watery  eye"  applied  to  this  disease. 
Soon,  pressure  over  the  lachrymal  sac  causes  a  reflux  into  the  eye  of  the 
lachrymal  secretion  mixed  with  more  or  less  purulent  matter,  or  the  same 
result  takes  place  spontaneously ;  the  conjunctiva,  especially  that  of  the 
lower  lid  and  inferior  portion  of  the  globe,  is  maintained  in  a  constant 
state  of  irritation  and  inflammation,  and  the  puncta  are  abnormally  red, 
swollen  and  prominent.  In  extreme  cases  an  abscess  forms  in  the  lachry- 
mal sac  or  neighboring  cellular  tissue,  opens  and  gives  rise  to  one  or  more 
fistuUe. 

These  affections  of  the  lachrymal  passages  may  occur  at  any  period  of 
the  constitutional  taint,  but  here,  as  elsewhere,  the  catarrhal  inflammation 
of  the  mucous  membrane  coincides,  as  a  rule,  with  the  secondary  stage  of 
the  disease,  while  the  deeper-seated  troubles  of  the  periosteum  and  the 
bones  are  the  development  of  the  tertiary  period. 

INIuch  may  be  done  for  the  relief  and  permanent  removal  of  obstructions 
of  the  lachrymal  passages  by  the  persevering  and  long-continued  use  of 
specific  remedies.  The  bichloride  of  mercury  and  iodide  of  potassium  may 
give  satisfactory  results.  Most  cases,  hoAvever,  refuse  to  yield  to  internal 
remedies  alone,  and  in  all  a  cure  may  be  expedited  by  a  resort  to  the  im- 
proved local  treatment  for  which  ophthalmic  surgery  is  so  largely  indebted 
to  Mr.  Bowman  of  the  Mooi'fields  Ophthalmic  Hospital.^ 

This  treatment  consists  in  slitting  up  the  canaliculi  as  far  as  the  caruncle, 
and  afterwards  dilating  the  passage  into  the  nose  by  means  of  graduated 
probes  as  we  would  a  stricture  of  the  urethra.  The  first  part  of  the  above 
procedure  is  often  sufficient  to  aflTord  great  relief  to  the  patient  by  opening 

'  See  Mr.  Bowman's  papers  in  the  Medical  and  Chirurgical  Transactions,  1851, 
and  in  the  Ophthalmic  Hospital  Reports  for  Oct.  1857  ;  also  Remarks  on  Diseases 
of  the  Lachrymal  Passages  by  the  author  in  the  Report  of  the  N.  Y.  Eye  Infirmary, 
N.  y.  Journal  of  Med.,  July,  1859. 


AFFECTIONS    OP    THE    LACHRYMAL    PASSAGES.  693 

a  free  communication  between  tlie  conjunctiva  and  sac,  and  by  preventino- 
collections  of  matter  in  the  latter  or  facilitating  their  evacuation.  One  or 
both  canaliculi  having  been  slit  up,  an  opportunity  is  afforded  to  explore 
the  nasal  passages  with  a  full-sized  probe  (about  one-twentieth  of  an  inch 
in  diameter),  and  to  ascertain  the  nature  of  the  obstruction.  If  this  be 
due  to  swelling  of  the  mucous  and  submucous  tissues  alone,  the  passage  of 
a  probe  repeated  every  two  or  three  days  for  a  few  weeks,  and  retained 
on  each  occasion  for  about  half  an  hour,  will  in  most  cases  suffice  to  re- 
establish the  patency  of  the  canal;  but  when  denuded  bone  can  be  felt, 
showing  that  the  disease  is  seated  in  the  periosteal  or  osseous  tissues,  Mr. 
Bowman's  method  will  sometimes  prove  unsuccessful,  and  it  becomes  neces- 
sary to  resort  to  the  following  course  of  treatment.  If,  after  the  canaliculus 
has  been  slit  up,  explorations  with  a  small  Bowman's  probe  show  that  the 
seat  of  the  trouble  is  in  the  lining  membrane  or  periosteum  of  the  canal, 
whether  this  be  from  simple  thickening  or  from  an  actual  stricture, 
then  the  upper  canaliculus  should  also  be  slit  up  and  the  orifice  made  by 
the  juncture  of  the  two  wounds  enlarged,  and  a  long  slender  knife,  such 
as  Agnew's^  lachrymal  knife,  should  be  passed  the  entire  length  of  the 
canal  and  the  membrane  freely  incised  down  to  the  bone.  After  the 
bleeding  which  relieves  the  congestion  of  the  parts  has  ceased,  the  largest 
size  of  Bowman's  probes  should  be  passed  so  as  to  fully  dilate  the  canal. 
This  having  been  once  accom[)lished,  it  is  usually  a  comparatively  easy 
matter  to  keep  the  canal  open  by  the  occasional  use  of  a  smaller  probe. 

In  long-standing  chronic  cases,  where  there  is  not  much  active  inflam- 
mation, instead  of  a  probe,  a  piece  of  lead  wire  of  the  same  size  as  a  probe 
may  be  inserted  and  left  for  a  day  or  two,  or  even  for  a  week  or  more, 
until  the  divided  stricture  and  membrane  have  healed.  Weak  injections 
of  nitrate  of  silver  through  the  sac  and  nasal  canal,  by  means  of  a  small 
syringe  such  as  is  used  for  hypodermic  injections,  may  often  be  used  with 
benefit  once  or  twice  a  week.  These  should,  however,  never  be  stronger 
than  a  grain  to  the  ounce. 

Sometimes  cases  appear  with  every  appearance  of  a  severe  trouble  in  the 
sac  and  canal,  showing  a  large  and  reddened  tumefaction  which  is  ex- 
quisitely painful  to  the  touch,  and  in  which  there  is  a  slight  sense  of  fluctua- 
tion with  every  indication  of  confined  pus.  There  is  however  little  or  no 
epiphora,  and  no  pus  escapes  when  the  canalicidi  are  slit  up.  INIoreover, 
the  probe  shows  that  there  is  no  stricture  or  even  narrowing  of  the  canal. 
The  real  seat  of  the  trouble  is  then  not  in  the  sac  or  canal,  but  in  the 
periosteum  of  the  nasal  process  of  the  superior  maxillary  bone  and  contigu- 
ous parts.  In  this  case  the  incision  should  be  made  from  the  outside  and 
be  deep  enough  to  go  through  the  periosteum.  The  cut  should  be  kept 
open  for  a  day  or  two,  and  small  poultices  used  for  only  twenty  minutes  or 
so  once  or  twice  a  day.  Sometimes,  though  rarely,  we  see  a  permanent 
thickening  of  the  bones  in  this  region,  which  makes  a  distressing  detbrmity. 

1  For  an  admirable  article  on  "  Tlic  Treatment  of  Laclirymal  Diseases,"  see  The 
American  Practitioner,  Jan.  1871,  p.  1.     C.  R.  Agnew,  M.D. 


694  AFFECTIONS    OF    THE    EYES. 

Sliould  tliis  treatment  not  snffice,  it  sometimes  becomes  necessary  to 
resort  to  obliteration  of  the  sac  and  canaliculi  (wliich  should  always  be 
included)  by  the  actual  cautery,  or  to  wait  for  the  slow  elimination  of  the 
carious  portions  of  bone  under  the  internal  administration  of  iodide  of 
potassium.  The  old-fashioned  style  has  been  entirely  abandoned.  The 
danger  and  inconvenience  attending  its  employment  far  more  than  counter- 
balance any  benefit  that  can  be  derived  from  it. 

Syphilitic  Affections  of  the  LAciinyjiAL  Gland. 

The  only  recorded  case  of  affection  of  this  gland  is,  according  to  Dr.  R.  W. 
Taylor,'  that  reported  by  Chalons"''  of  Luxembourg.  "  This  case  was  that  of 
a  person  in  the  first  year  of  his  disease,  having  lesions  of  an  exanthematous 
character  and  an  iritis.  CoincJdently,  these  glands  were  observed  to  be- 
come swollen,  and  their  increased  size  was  very  perceptible,  as  they  pnshed 
the  up])er  lids  forwards.  The  gland  on  the  right  side  was  much  more 
tumefied  than  its  fellow,  and  caused  the  eyelid,  which  was  slightly  reddened, 
to  droop  down  over  the  eye  as  in  the  affection  named  ptosis.  There  was 
no  pain,  and  the  symptoms  were  of  a  mild  character.  The  appearance  of 
the  person  is  described  as  being  very  peculiar.  The  swellings  subsided 
under  the  infiuence  of  a  mercurial  treatment." 

The  writer  has  seen  one  or  two  similar  cases  in  which  inflammation  of 
the  lachrymal  gland  or  surrounding  tissue  was  supposed  to  exist.  In  all 
these  cases,  however,  exce])ting  one,  there  was  no  specific  history  and  no 
concurrent,  nor  had  there  been  any  anterior  manifeslations  of  syphilis. 
In  one  case  there  was  a  doubtful  specific  history  in  a  man  of  forty  years, 
and  the  trouble,  which  had  lasted  a  long  time,  yielded  at  once  to  very 
large  doses  of  iodide  of  potassium.  In  all  the  trouble  was  one-sided. 
Dr.  Taylor  also  mentions  in  the  same  paper  two  unique  cases  where 
there  was  gummy  infiltration  into  the  caruncles. 

Syphilitic  Affections  of  the  Eyelids. 

These  lesions  are  very  rare,  but  when  they  do  occur  they  present  the 
same  general  appearances  and  characteristics  that  the  same  lesions  do  in 
the  corresponding  tissues  elsewhere  in  the  body,  and  they  may  for  clinical 
purposes  be  divided  into  eruptions,  infiltrations,  and  ulcerations. 

An  eru|)tion  of  a  pustular  syphilide,  of  ecthyma,  of  ulcerating  rnpia,and 
other  forms  may  occur  on  the  eyelids,  and  especially,  according  to  Lance- 
reaux,  in  the  tertiary  period,  the  external  surface  of  the  lid  may  be  the 
seat  of  ulcerating  or  even  serpiginous  syphilides,  which,  by  cicatricial  con- 
traction, may  cause  ectropion  or  other  displacements  of  the  lid.  Lawrence 
states  that  the  lining  mucous  membrane  may  share  in  the  eruption  which, 
as  a  rule,  affects  it  superficially.     He  mentions  a  case  of  general  pai)ular 

'  American  Journal  of  the  Medical  Sciences,  vol.  Ixix,  1875,  p.  370. 

*  Adenitis  Lachrymalis  Syphilitica,  Preuss.  Vereins  Zeitung,  No.  42,  1859. 


SYPHILITIC    AFFECTIONS    OF    THE    EYELIDS.  695 

eruption  in  a  man  with  specific  iritis  in  whom  papules  were  also  seen  on  the 
inner  surface  of  the  lid.  The  writer  has  seen  a  similar  case  where  the 
papules,  which  covered  the  external  surface,  extended  a  little  beyond  the 
juncture  of  the  mucous  membrane  with  the  edge  of  the  lid. 

Sypliilitic  eruptions  of  the  eyelids  are  more  frequent  in  infants  affected 
with  hereditary  syphilis,  than  in  adults.  The  external  surface  of  the  lids 
is  the  seat  of  an  eruption  of  pustules,  which  run  into  each  other,  break, 
and  leave  the  skin  excoriated  and  red.^  Tlie  conjunctiva  of  the  lid  and 
the  globe  may  become  involved  through  extension  of  the  inflammation, 
and  the  cornea  destroyed  by  infiltration  of  pus.  This  affection  may  be 
distinguished  from  oplithalmia  neonatorum  by  its  later  development — the 
latter  appearing  about  the  third  day  and  the  former  several  weeks  after 
birth — and  by  the  presence  of  the  eruption  upon  the  external  surface  of 
the  lids  to  which  the  conjunctivitis  is  only  secondary. 

Syphilitic  Ulcerations — These  may  be  either  due  to  a  chancroid  or  to 
true  syphilis,  and  be  either  primary  or  secondary. 

Soft  chancres  upon  the  lids  are  of  extreme  rarity  ;  I  have  never  seen 
any  myself,  but  Galezowski"  and  Hirscher*  have  each  reported  a  case. 

The  true  sypliilitic  ulcer  is  more  common,  and  may  occupy  any  part 
of  the  external  or  internal  surface  of  the  lid,  and  may  either  continue 
superficial,  or,  gradually  extending,  may  involve  all  the  tissues  of  the  lid. 
It  most  frequently  occurs  on  the  delicate  skin  on  the  margin  of  the  lid, 
or  in  the  cul-de-sac,  where  it  usually  begins  as  a  papule,  to  be  followed  by 
the  appearance  of  a  superficial  or  excavated  sore  having  an  indurated 
base,  the  induration  being,  as  a  usual  thing,  deeper  and  more  marked  here 
than  in  other  parts  of  the  body.  The  ulcer  is  generally  accompanied  by 
inflammation  and  swelling  of  the  pre-auricular  and  submaxillary  glands. 
This  must  be  considered  the  most  valuable,  and  sometimes  the  only,  diag- 
nostic mark  of  the  true  nature  of  the  trouble.  For  without  this  sign, 
tliese  primary  ulcerations  may  be,  as  indeed  they  have  been  more  than 
once,  taken  for  simple  styes  or  a  discharging  tarsal  tumor.  I  have  seen 
two  cases  of  primary  ulcers  on  the  inner  surface  of  the  lid,  which  simu- 
lated so  exactly  a  tarsal  tumor  with  a  small  opening,  as  to  render  the  dis- 
crimination J)etween  the  two  at  first  impossible.  The  only  guide  to  a 
certain  diagnosis  was  the  rapid  development  of  an  adenitis  in  both  the  pre- 
auricular and  submaxillary  glands,  which,  according  to  Zeissl,  seldom 
occurs  in  any  but  strumous  subjects.  In  neither  of  these  cases,  however, 
were  there  the  slightest  signs  of  a  strumous  diathesis.  The  diagnosis  was, 
however,  corroborated  in  the  fullest  manner  by  the  successive  appearances 
of  secondary,  and  in  one  case  of  tertiary  manifestations  in  other  regions. 

In  the  secondary  period,  syphilitic  lesions  of  the  inner  surface  of  the 
lids  appear  as  small,  circumscribed,  prominent  spots,  usually  of  a  mode- 
rate degree  of  vascularity,  though  not  always,  as  tlie  surrounding  tissue 
sometimes  becomes  congested,  and  the  congestion  may  then  extend  to  the 

'  Figured  by  Deveboie,  Clinique  de  la  maladie  syphilitique,  PI.  37. 
2  Galezowski,  Journal  d'ophtlialmologio,  niai  et  juin,  1872. 
'  HiBSCUER,  Wiener  med.  Wocheuschrift,  No.  72,  73,  74.     1866. 


GOG  AFFECTIONS    OF    THE    EYES. 

ocular  conjunctiva.  The  color  of  these  spots  sometimes  varies  from  a 
grayish-red  to  a  yellow  or  even  copper  color.  INIucous  patches,  pure  and 
simple,  may  occur  on  the  palpebral  conjunctiva,  and  they  present  the  same 
general  characteristics  as  they  do  elsewhere  on  the  body. 

Secondary  ulcerations  of  the  eyelids  usually  begin  as  gummy  tumors  or 
as  submucous  infiltrations.  They  are  very  destructive  of  tissue  and  often 
leave  behind  them  a  scar  which,  witli  the  destruction  of  the  hair  follicles 
and  the  consequent  loss  of  hair,  is  for  some  a  diagnostic  mark.  Still  the 
fact  should  not  be  lost  sight  of  that  the  same  result  may  occur  from  a  sim- 
ple furuncle  or  an  aggravated  sty. 

Secondary  ulcers  are  almost  always  situated  near  the  free  border,  en- 
croaching upon  the  mucous  membrane  or  upon  the  skin,  and  sometimes,  as 
in  a  number  of  cases  collected  by  Mackenzie,^  causing  complete  destruction 
of  the  lid.  I  have  seen  but  one  case  in  a  lad  aged  nineteen,  affected  with 
syphilitic  disease  of  the  lachrymal  passages  and  nodes  upon  the  tibia,  and 
who  had  several  small  excavated  ulcers  upon  the  mucous  membrane  of  the 
lower  lid  bordering  upon  its  free  margin.  His  disease  could  be  traced  to 
a  chancre  contracted  three  years  previously,  and  disappeared  under  iodide 
of  potassium  and  mercurials.  These  ulcerations  may  be  mistaken  for 
ophthalmia  tarsi,  and  epithelial  cancer,  or,  when  situated  near  the  inner 
canthus,  for  disease  of  the  lachrymal  passages. 

Moreover  Zeissl  declares  that  the  gross  and  microscopical  appearances 
of  the  initial  lesion  are  so  similar  that  they  can  hardly  be  distinguished, 
and  moreover  the  rapid  and  enormous  growth  of  a  papule  on  the  lid  some- 
times causes  it  to  resemble  a  gumma. 

Sometimes  infiltrations  into  the  substance  of  the  lid  between  the  cartilage 
and  the  external  surface  do  not  ulcerate,  but  remain  for  a  long  time  as 
nodules  varying  in  size  from  a  shot  to  a  large-sized  filbert.  Under  these 
circumstances  the  skin  over  these  nodules  is  but  slightly  if  at  all  reddened, 
and  in  this  case  these  protuberances  bear  a  close  resemblance  to  tarsal 
tumors  or  chalaza  for  which  they  have  been  mistaken.  These  masses 
usually  resolve  themselves  under  the  free  use  of  antisyphilitic  remedies, 
especially  the  mercurials. 

Syphilitic  inflammation  of  the  tarsal  cartilage  has  been  reported  latterly 
by  various  observers  under  the  name  of  tarsitis  syphilitica  (Magawby, 
Fuchs,  Yogel,  Bull,  and  others).  It  is  characterized  by  a  thickening  from 
inflammatory  infiltration  of  the  cartilage,  which  usually  maintains  its  sha[)e, 
and  swelling  of  the  lid,  in  which  the  skin  may  or  may  not  be  involved. 
As  a  rule  it  is  found  that  after  the  acute  stage  has  passed  and  the  tumor  has 
disappeared,  the  cartilage  has  lost  its  normal  elasticity  and  resistance. 
The  affection  is  very  obstinate,  lasting  over  several  weeks  if  not  months, 
and  it  is  apt  to  be  followed  by  a  more  or  less  complete  loss  of  the  ciliae. 

Finally  inflammation  due  to  constitutional  syphilis  may  attack  the  ten- 
dons and  fascite  of  the  muscles  of  the  globe  and  especially  the  capsule  of 
Tenon.  This  is  always  a  grave  lesion,  as  deep-seated  abscesses  are  liable  to 
form,  hemmed  in  by  the  fascia?  and  thecu).    Besides  constitutional  ti'eatment, 

'  Diseases  of  the  Eye,  Phil,  ed.,  1855,  p.  160. 


AFFECTIONS    OF    THE    CONJUNCTIVA. 


697 


these  affections  often  require  surgical  interference  in  the  way  of  deep  and 
broad  incisions  into  the  orbit,  especially  in  the  line  of  the  muscles  and  close 
to  the  globe.  They  are  apt  to  end,  in  spite  of  all  care  and  skill,  in  total  de- 
struction of  the  globe  through  panopthalmitis. 

Affections  of  the  Conjunctiva. 

If  we  except  the  ulcerations  of  the  lids  already  described  as  sometimes 
encroaching  from  the  mucous  membrane  of  the  internal  surface  upon  the 
cul-de-sac,  the  conjunctiva,  that  is,  the  ocular  conjunctiva,  is  veiy  rarely 
the  seat  of  syphilitic  manifestations. 

Savy,'  however,  reports  a  case  (Fig.  128)  of  a  syphilitic  papule  de- 
veloped upon  the  ocular  conjunctiva,  three  millimetres  above  the  cornea. 

Fi?.  128. 


Syphilitic  papule  of  the  conjunctiva. 

The  patient  contracted  syphilis  six  months  before,  and  had  over  the 
whole  body  an  obstinate  lenticular  eruption  ;  the  eyelids  were  red,  the 
lashes  had  fallen  off,  and  the  papular  eruption  had  extended  to  the  under 
surface  of  the  lids.  A  cure  was  obtained  after  three  weeks,  specific  treat- 
ment.    Savy  quotes  two  similar  cases  from  P.  Horteloupand  from  Lailler. 

Infants  tainted  with  hereditary  syphilis  are,  indeed,  more  frequently  than 
others  the  subjects  of  ophthalmia  neonatorum,  to  which  they  are  peculiarly 
exposed  from  their  general  cachectic  condition  and  the  frequency  of  vagi- 
nal discharges  in  their  syphilitic  mothers  ;  but  there  is  no  direct  connection 
between  their  hereditary  taint  and  the  purulent  inflammation  of  the  con- 
junctiva, which  usually  makes  its  appearance  before  the  development  of 
other  symptoms. 

Mr.  Smee*  and  Mr.  France'  have  met  with  "  blotches"  upon  the  con- 
junctiva, coinciding  with  syphilitic  eruptions  upon  the  integument  and  dis- 
appearing under  mercurial  treatment.     The  appearances,  as  described  by 

'  Claude  Savy,  Contribution  i  I'etude  des  erujitions  de  la  conjunctive,  Theso  de 
Paris,  1876. 

2  London  Medical  Gaz.,  1844,  pp.  347-8. 

3  Guy's  Hosp.  Repts.,  third  series,  vol.  vii. 


698  AFFECTIONS    OF    THE    EYES. 

Mr.  France,  are  as  follows  :  "  This  form  of  disease  presents  itself  as  a 
limited  and  well-defined  discoloration  of  the  mucous  membrane  of  the 
globe,  which,  within  the  aftccted  area  is  slightly  thickened  and  raised,  but 
not  conspicuously,  if  at  all,  more  vascular  than  the  neighboring  surface. 
There  does  not  seem  to  be  any  disposition  to  ulceration,  as  when  the  margin 
of  the  lid  is  attacked  with  syphilis  ;  there  is  no  pain  and  no  morbid  dis- 
charge." Mr.  France  met  with  two  cases,  of  which  he  gives  a  plate,  Mr. 
Smee  with  only  one. 

There  would  appear  to  be  no  reason  why  the  ocular  conjunctiva  should 
not  be  affected  both  by  true  chancre  and  chancroid.  I  have  never  seen 
the  occurrence  of  either,  but  as  this  work  is  passing  through  the  press, 
Boucheron  reports  a  well  authenticated  case  of  a  true  chancre  of  the  semi- 
lunar fold  conveyed  in  a  kiss  from  mucous  patches  in  the  mouth,  and  refers 
to  another  in  the  same  situation  in  a  physician  who  rubbed  his  eye  to  re- 
lieve itching  with  his  fingers  soiled  in  examining  a  case  of  syphilis  (Gaz. 
d.  hop.,  14  juin,  1870). 

I  have  seen  several  times  what  I  have  taken  to  be  ulcerations  of  a 
secondary  nature,  such  as  have  been  described  by  Magni,  Noyes,^  and 
others.  The  latter  says  the  common  site  for  these  ulcerations  is  near  the 
margin  of  the  cornea,  where  a  reddened  and  elevated  spot  appears,  resem- 
bling a  severe  phlyctenule.  It  rises  higher,  and  is  more  extensive  than 
such  eruptions  usually  are,  and  it  soon  begins  to  ulcerate.  The  surface  not 
only  becomes  excavated,  but  shows  a  jelly-like  semi-trans})arent  tissue 
about  the  eroded  part,  and  this  may  spread  to  the  cornea,  which  then  often 
has  a  hazy  appearance  in  the  neighborhood  of  the  ulceration,  giving,  espe- 
cially just  before  the  surface  of  the  protuberance  begins  to  ulcerate,  the 
picture  of  episcleritis.  The  search  for  corroborative  symptoms  of  syphilis 
in  other  parts  of  the  body  will  usually  be  rewarded  by  success. 

Magni  describes  an  affection  under  the  name  of  kerato-conjunctivitis 
gummosa,  in  a  woman  who  was  affected  with  constitutional  syphilis. 
There  appeared,  on  the  ocular  conjunctiva,  several  semi-globular  tumors, 
varying  in  size  from  the  head  of  a  pin  to  that  of  a  bean.  These  were  of 
a  whitish  color  at  their  summits  and  red  at  the  base,  and,  except  when 
situated  near  the  cornea,  were  freely  movable  with  the  conjunctiva. 

The  ocular  membrane,  moreover,  according  to  Desmarres,^  is  sometimes 
the  seat  of  syphilitic  tubercles  coexisting  with  a  similar  eruption  upon  the 
skin.  This  author  relates  the  case  of  a  patient  affected  with  syphilitic 
iritis,  in  whom  one  of  the  so-called  condylomata  of  the  iris,  situated  near 
its  external  margin,  penetrated  the  sclerotic  and  formed  a  protuberance 
beneath  the  conjunctiva,  which,  moreover,  was  studded  on  every  side  with 
small,  indolent,  hard,  and  oblong  tumors,  exactly  similar  to  an  eruption  of 
sypiiilitic  tubercles  upon  various  portions  of  the  integument.  The  disease 
disappeared  under  mercurial  treatment. 

The  mass  which  penetrated  the  sclera  was  prol)ably  a  gummy  tumor  of 
the  ciliary  body,  about  which  more  will  be  said  a  little  later. 

•  Syphilis  of  the  Eye,  1874,  p.  4. 

2  Traite  des  maladies  des  yeux,  t.  ii,  p.  21G. 


SYPHILITIC    AFFECTIONS    OF    THE    CORNEA.  G99 

"VVecker,  Estlander,  Bull,  ami  others  have  reported  cases  of  gummy  in- 
filtration of  the  ocular  conjunctiva.  In  most  of  these  the  product  in  the 
conjunctiva  has  appeared  to  be  simply  the  extension  of  that  in  the  sclera 
from  continuity  of  tissue.  Dr.  Bull's^  case  is  worthy  of  note  as  possessing 
what  would  appear  to  be  an  independent  focus  of  infiltration  in  the  con- 
junctiva proper,  or,  at  least,  in  the  limbus.  This  was  in  the  case  of  a 
man,  the  victim  of  a  combination  of  constitutional  syphilitic  manifesta- 
tions, among  which,  "there  was  a  peculiar  eruption  upon  the  hands  and 
face,  composed  of  elevated  spots  with  flat  tops,  some  round,  others  oval, 
yellowish-red  in  color,  with  a  narrow  dark-red  areola,  neither  painful  nor 
tender  to  the  touch,  and  presenting  a  mid-state  between  vesiculation  and 
pustulation. 

"  The  eyes  were  almost  identical  in  appearance.  Surrounding  the  corneae 
there  was  a  growth,  most  marked  on  the  outer  and  lower  sides,  varying  in 
height  from  one  and  a  half  to  two  lines,  seated  in  and  beneath  the  ocular 
conjunctiva.  This  growth  extended  away  from  the  cornea  on  all  sides 
about  one-third  of  an  inch,  was  pale  yellow  in  color,  moderately  hard  to 
the  touch,  with  an  irregular,  knobby  surface  and  apparently  destitute  of 
vessels.  The  conjunctiva  was  firmly  adherent  to  this  growth,  and  the 
cornea  was  imbedded  in  this  wall  like  a  watch-crystal  in  its  frame.  On 
being  incised,  it  cut  like  brawn  and  the  hemorrhage  was  very  sliglit. 
Upon  the  sclera  of  each  eye,  between  the  tendons  of  the  superior  rectus 
and  external  rectus  muscles,  and  partially  covering  the  latter,  was  an 
extensive  and  extremely  well-marked  gummy  infiltration  of  the  sclera,  very 
vascular,  very  tender  to  the  touch,  and  especially  painful  when  the  eyes 
were  turned  outwards.  This  infiltration  extended  backwards  symmetri- 
cally in  the  two  eyes,  but  was  somewhat  more  extensive  in  the  right  eye. 
The  media  were  clear,  and  an  ophthalmoscopic  examination  revealed 
nothing  abnormal  in  the  deeper  tunics  of  the  eyes." 

Syphilitic  Affections  of  the  Cornea. 

While  ulceration  of  the  cornea  with  loss  of  tissue  is  in  non-specific 
cases  the  commonest  form  of  disease  to  which  this  membrane  is  liable,  in 
syphilis,  ulceration  rarely,  according  to  some  never,  occurs  as  the  direct 
result  of  the  constitutional  taint.  When,  therefore,  an  inflammation  of 
this  membrane  does  occur,  it  is  usually  in  the  substance  of  tiie  cornea  and 
in  the  form  usually  known  as  parenchymatous  keratitis.  And  this  inter- 
stitial afiection  again  may  show  itself  as  diflTuse  or  punctate.  In  these 
forms,  moreover,  it  is  usually  the  result  of  hereditary  syphilis. 

Diffuse  keratitis  is  usually  ushered  in  by  a  slight  pericorneal  injection 
and  with  a  slight  grayish  opacity  near  the  centre  of,  and  in  the  substance 
of  the  cornea.  Tlie  haziness  gradually  increases  until  the  greater  part  of 
the  c_ornea  is  involved,  giving  to  this  membrane  the  appearance  of  ground 
glass,  especially  wlien  the  epithelial  layer  is  implicated.     It  is  usually  in 

'  American  Journal  of  the  Medical  Sciences,  October,  1878. 


700  AFFECTIONS    OF    THE    EYES. 

the  beginning  not  accompanied  by  much  pain  or  photophobia,  tliough  both 
may  be  present,  together  with  abundant  lachrymation,  especially  as  the 
disease  progresses  to  the  deeper  parts  of  tlie  cornea.  There  is  little  vas- 
cularity as  a  rule,  though,  especially  at  tlie  periphery,  minute  vessels  may 
be  descried,  wliich,  increasing  in  number  and  extent,  may  give,  especially 
at  a  little  distance,  a  rosy  hue  to  the  cornea.  I  have  seen  cases  in  which 
there  has  appeared  to  be  an  interstitial  hemorrhage,  so  deep  and  close  was 
the  injection.  In  one  case,  indeed,  the  entire  cornea  was  a  blood-red  mass, 
as  if  the  bleeding  liad  occurred  into  the  very  substance  of  the  membrane, 
the  epithelial  layer  retaining  its  polish.  Diffuse  keratitis  is  the  form  which 
the  disease  usually  takes  in  young  children,  while  the  punctate  variety 
appears  later  in  life,  or,  at  least,  such  has  been  my  observation.  Mr. 
Jonathan  Hutchinson^  has  expressed  the  opinion,  founded  upon  a  lengthy 
and  ably  conducted  series  of  observations,  that  the  peculiar  inflammation 
of  the  cornea,  met  with  for  the  most  part  between  the  ages  of  three  and 
twenty,  and  known  by  the  name  of  "  strumous  corneitis,"^  is  always  due 
to  hereditary  syphilis.  In  his  attempt  to  establish  this  point  Mr.  Hutch- 
inson has  attached  no  little  importance  to  certain  peculiarities  in  the  form, 
size,  and  color  of  the  pei-manent  incisor  teeth,  which  he  regards  as  diag- 
nostic of  inherited  syphilitic  taint,  and  which  he  states  are  all  but  invari- 
ably coexistent  with  strumous  keratitis. 

In  describing  this  condition  Mr.  Hutchinson  says:  "As  diagnostic  of 
hereditary  sypliilis,  various  peculiarities  are  often  presented  by  the  others 

Fig.  129. 

MffliBifiiiiiiin 


"The  teeth  converge  towards  each  other,  are  very  short,  have  a  vertical  notch  or  cleft  in  their 
free  edges,  and  are  also  very  narrow  from  side  to  side  at  their  edges,  not  being  so  wide  there  as 
their  neclis." 

especially  the  canines,  but  the  upper  central  incisors  are  the  test  teeth. 
When  first  cut  these  teeth  are  usually  short,  narrow  from  side  to  side  at 
their  edges  and  very  thin.  After  a  while  a  crescentic  portion  from  their 
edge  breaks  away,  leaving  a  broad,  shallow,  vertical  notch  which  is  per- 

Fig.  130. 


manent  for  some  years,  but  between  twenty  and  thirty  usually  becomes 
obliterated  by  the  premature  wearing  down  of  the  tooth.  The  two  teeth 
often  converge,  and  sometimes  they  stand  widely  apart.     In  certain  in- 

'  Ophth.  Hosp.  Rep.,  vol.  i,  p.  229. 

2  The  name  "Keratitis"  is  much  preferable  to  "  Corneitis." 


SYPHILITIC    AFFECTIONS    OP    THE    CORNEA.  701 

stances  in  which  tlie  notching  is  either  wholly  absent  or  but  slightly 
marked,  there  is  still  a  peculiar  color  ('a  dirty  brownish  hue  resemblino' 
that  of  bad  size'^),  and  a  narrow  squareness  of  form,  which  are  easily 
recognized  by  the  practised  eye."^  The  first  set  of  teeth  do  not  exhibit 
this  malformation. 

Since  the  publication  of  the  former  edition  of  this  Avork,  I  have  care- 
fully examined  into  the  symptoms  and  histories  of  the  numerous  cases  of 
interstitial  keratitis  coming  under  my  care,  and  have,  in  so  many  instances, 
been  able  to  confirm  Mr.  Hutchinson's  statements  relative  to  the  deformity 
of  the  teeth,  and  a  clearly  marked  syphilitic  taint  inherited  from  the 
parents,  that  I  can  testify  to  the  general  correctness  and  great  value  of 
his  observations,  although  I  am  not  prepared  to  say  that  interstitial  kera- 
titis is  always  due  to  congenital  syphilis.  In  some  instances  I  have  not 
been  able  to  satisfy  myself  that  the  parents  had  been  affected  with  this 
disease,  but  the  difficulty  of  such  inquiry  is  well  known,  and  the  truth 
often  escapes  detection. 

It  has  been  the  custom  from  time  to  time  since  Mr.  Hutchinson  made 
his  observations  to  question  the  validity  of  his  views,  both  as  to  the  fact  of 
interstitial  keratitis  being  due  to  hereditary  syphilis  and  the  diagnostic 
value  of  the  so-called  characteristic  teeth.  Thus  it  has  been  asserted  not 
only  in  England  but  on  the  Continent,  and  especially  in  Germany,  that 
the  disease  may  be  the  result  of  mal-nutrition  in  scrofulous  and  rickety 
subjects,  and  it  has  been  maintained  that  the  malformation  of  the  teeth  is 
the  simple  arrest  of  development  in  a  perverted  constitution  from  other 
causes  than  syphilis.  Thus  Maunther^  declares  that  "  the  German  oph- 
thalmologists have  in  no  way  been  able  to  endorse  the  theory  of  Hutchinson;" 
while,  on  the  other  hand,  Forster,*an  eminent  German  authority,  states  at 
a  still  more  recent  date  just  the  contrary,  and  maintains  that  "  the  view 
that  interstitial  and  parenchymatous  keratitis  is  frequently  due  to  hereditary 
syphilis  is  constantly  gaining  more  adherents." 

It  would  be  out  of  place  in  a  work  like  the  present  to  go  deeply  into  a 
discussion  in  regard  to  matters  about  which  there  is  so  great  a  difference 
of  opinion,  but  I  may  state  briefly  that  I  believe  that  the  hereditary  taint, 
though  not  the  only,  is  still  the  predominating  cause  of  interstitial  kera- 
titis. And  this  I  consider  important  in  a  clinical  point  of  view,  for  I  can 
fully  confirm  Mr.  Hutchinson's  statement,  that  the  most  efficacious  treat- 
ment of  this  disease  in  the  majority  of  cases  is  by  means  of  mild  mercurials 
and  iodide  of  potassium  assisted  by  a  nourishing  diet,  fresh  air,  and  tonics. 

Keratitis  punctata  differs  from  the  diffuse  in  that  tlie  opacity  is  arranged 
in  small  circumscribed  spots  or  points.  These  as  a  rule  do  not  show  a  ten- 
dency to  coalesce.     Still  this  may  occur  so  that  the  masses  become  large 

'  Hutchinson,  on  tho  Means  of  Rccof^nizing  the  Subjects  of  Inherited  Syphilis  in 
Adult  Life,  Medical  Times  and  Gaz.,  Lond.,  Sept.  11,  1858,  p.  265.  Syphilitic 
Keratft's  in  a  Child,  aged  three  years,  London  Lancet,  Dec.  18,  1875. 

*  Ophtli.  Hosp.  Rep.  vol.  ii,  p.  96. 

'  Ziessl's  Lehrbucii  der  Syphilis,  1875,  p.  288. 

*  Handbuch  der  geaam.  Augenheilkunde,  vol.  vii,  p.  186,  1876. 


702  AFFECTIONS    OF    THE    EYES. 

enough  to  occcupy  a  quadrant  or  even  tlie  half"  of  the  corneal  tissue.  It 
also  differs  from  the  diffuse  in  being  deeper  seated  and  usually  of  a  deeper 
grayish  or  yellowish  color. 

Maunther  describes  a  form  of  punctate  keratitis  which  is  wortliy  of  notice 
from  the  fact  that  it  would  apjjcar  to  be  even  more  pathognomonic  of  sy- 
philis than  the  ordinary  keratitis  punctata,  and,  according  to  my  experience, 
rather  the  expression  of  the  acquired  than  the  hereditary. 

This  form  consists  in  the  corneal  tissue  being  studded  with  a  multitude 
of  minute  dots  not  larger  than  a  pin-point.  These  are  not,  as  one  would 
be  inclined  at  first  sight  to  infer,  on  the  membrane  of  Descemet  but  in  the 
substance  of  the  cornea  itself.  I  have  at  the  present  moment  a  most 
beautifully  marked  case  of  this  disease  in  a  young  woman  of  three  and 
twenty,  who,  when  I  first  saw  her  some  three  months  ago,  had  a  secondary 
eruption  on  the  legs,  arms,  and  neck.  Externally  notliing  whatever  was 
visible  which  would  suggest  the  slightest  trouble  with  either  eye,  and  the 
only  complaint  which  the  patient  made  was  that  she  had  noticed  acci- 
dentally that  she  did  not  see  as  well  as  formerly  with  her  left  eye.  There 
was  no  pain  and  no  lachrymation,  and  not  the  slightest  injection  of  the 
conjunctiva.  The  cornea  and  anterior  chamber,  moreover,  seemed  to 
have  their  normal  clearness  and  the  iris  was  normal  in  every  respect.  A 
glance  with  the  ophthalmoscope  showed,  however,  the  cornea  to  be  the  seat 
of  a  multitude  of  most  minute  dots,  none  of  which  were  larger  than  a  pin'i? 
point.  By  means  of  oblique  illumination  the  most  anterior  of  these  could 
be  seen  in  their  real  color,  which  was  of  a  dingy  gray  or  dirty  white.  The 
trouble  continued  without  any  perceptible  change  and  without  any  inflam- 
matory symptom  whatever  for  nearly  three  months,  when  on  catching  cold 
there  was  some  pain  in  the  eye  and  a  slight  pericorneal  injection  which 
rapidly  subsided.  A  vigorous  antisyphilitic  treatment  has  been  pursued 
from  the  first  and  within  the  last  week  or  two  the  dots  have  begun  to  dis- 
appear, these  only  remaining  now  in  the  central  portions  of  the  cornea. 

The  treatment  of  these  syphilitic  aflfections  does  not  differ  from  that  in 
the  idiopathic  form  and  consists  in  the  use  of  atropine  with  i)rotection  from 
light  by  means  of  colored  glasses,  antisyphilitic  remedies  with  a  judicious 
administration  of  tonics,  diet,  and  fresh  air. 

It  is  moreover  sometimes  necessary  to  perform  paracentesis  or  even  iri- 
dectomy. 

Syphilitic  Affections  of  the  Sclera. 

These,  like  the  non-specific,  may  be  divided  into  two  principal  classes: 
those  affecting  the  superficial  tissue,  or  episcleritis,  and  those  affecting  the 
interstitial  layers,  or  parenchymatous  scleritis.  To  these  some  sypliilo- 
graphers  add  a  third,  or  scleritis  gummosa,  when  the  sclera  is  the  seat  of 
this  specific  infiltration  or  product.  Episcleritis  begins  commonly  as  a 
small  hyperasmic  spot,  usually  about  a  line  from  the  margin  of  the  cornea. 
As  the  inflammation  increases  in  extent  and  degree,  the  s[iot  looks  very 
much  like  a  phlyctenula,  though  the  coloration  is  more  subdued,  and,  after 


SYPHILITIC    AFFECTIONS    OF    THE    SCLERA.  703 

a  while,  assumes  a  violet  or  purple  tinge.  On  close  inspection,  the  con- 
junctiva is  seen  to  be  but  little  if  at  all  implicated,  and,  as  a  rule,  the  new 
formation  has  the  appearance  of  a  bulging  of  the  surface  which  merges 
gradually  into  the  surrounding  tissue,  rather  than  a  circumscribed  growth, 
though  even  this  may  occur,  so  that  it  resembles  a  defined  tumor  the  size  of 
half  a  pea,  or  even  larger.  The  favorite  spot  for  the  development  of  this 
localized  inflammation  is  near  the  insertion  of  the  external  rectus  muscle  or 
between  this  and  the  superior  rectus.  Still,  any  part  of  the  anterior  portion 
of  tlie  sclera  may  be  affected,  or  more  parts  than  one,  either  successively 
or  at  the  same  time.  In  this  case  the  spots  may  spread  and  then  coalesce, 
until  the  greater  part  of  the  circumference  near  the  cornea  is  affected. 

When  the  inflammation  is  confined  to  the  episcleral  tissue,  there  is,  as  a 
usual  thing,  but  little  pain,  lachrymation,  or  photophobia,  though  all  three 
may  be  present. 

The  trouble  is,  however,  apt  to  propagate  itself  to  the  neighboring  tissues, 
so  that  the  cornea,  iris,  and  ciliary  body,  one  or  all,  may  become  impli- 
cated. In  the  last  case,  a  kerato-irido-cyclitis  is  produced,  than  which 
there  is  no  condition  of  ocular  trouble  more  to  be  dreaded,  or  one  which 
will  more  tax,  even  if  it  does  not  overcome,  the  skill  and  resources  of  the 
surgeon.  The  implication  of  the  cornea  is  usually  shown  by  a  grayish 
diffuse  opacity  corresponding  to  the  seat  of  the  inflammatory  spot  and 
extending  usually  in  a  triangular  shape  into  the  clear  area  of  the  cornea ; 
the  participation  of  the  iris  manifests  itself  by  adiiesions  and  sometimes  by 
exudation  into  the  papillary  space ;  and  that  of  tlie  ciliary  body  by  the 
usual  signs  of  cyclitis.  When  the  episcleritis  is  due  to  a  gummy  deposit, 
it  may  resolve  itself  gradually,  which  is  the  rule  under  specific  remedies, 
or  it  becomes  eroded  at  its  apex,  forming  an  excavation  with  more  or  less 
ragged  edges,  while  the  area  is  occupied  by  a  jelly-like  substance  of  a 
grayish  or  yellowish  color;  and  it  is  more  than  probable  that  some  of  the 
infiltrations  which  present  these  appearances,  and  which  have  been  de- 
scribed as  belonging  to  the  conjunctiva  proper,  have  had  their  origin  in 
the  episcleral  tissue.^ 

Kare  as  the  above  affections  are,  those  due  to  parenchymatous  scleritis 
are  rarer  still.  That  sucli  exist,  however,  I  think  there  can  be  no  doubt. 
The  trouble  usually  begins  by  a  circum-corneal  zone  of  injection  of  a  very 
delicate  rose  or  pink  color  which  often,  after  the  disease  has  continued  a 
short  time,  passes  into  a  violet  or  purplish  tinge,  which  close  inspection 
shows  to  be  due,  not  to  vascularity  of  the  conjunctiva,  but  of  the  sclera 
itself.  The  injection  gradually  extends  backwards  until  the  whole  ante- 
rior zone  of  the  eye  presents  the  delicate  rosy  hue  mentioned  above, 
whicli  differs  entirely  from  the  coarser  mesh-like  injection  of  an  early 
conjunctivitis  on  the  one  hand,  or  the  deep  red  of  iritis  on  the  other. 
The  trouble  may  continue  for  a  long  time  in  a  low  chronic  type,  without 
much  photophobia,  pain,  or  lachrymation,  though  the  latter  two  m^y  be 
present  in  an  intense  degree,  and  then  the  disease  forcibly  reminds  one  of 

'  Stukois,  Scleritis  Syphilitica,  Archives  of  Dermatology,  January,  1875,  p.  112. 


704  AFFECTIONS    OF    THE    EYES. 

the  description  of  Mliat  the  ohler  writers  called  rheumatic  ophthalmia. 
Strange  to  say,  through  it  all  the  iris  may  not  become  implicated,  dilating 
ad  maximum  under  atropine,  apparently  even  to  an  abnormal  degree,  as 
sometimes  the  merest  possible  trace  of"  the  membrane  remains  visible. 
This  is  due,  I  think,  to  the  fact  that  the  limbus  becomes  congested  and 
slightly  salient,  thus  encroaching  upon  and  narrowing  the  area  of  the  clear 
cornea.  I  have  several  times  seen  this  affection  in  those  who  had  recently 
recovered  from  a  severe  and  protracted  attack  of  gonorrhoea,  and  thus 
perhaps  representing  the  analogue  of  the  much-disputed  gonorrhoeal  rheu- 
matism. Here,  as  elsewhere,  there  is,  of  course,  always  a  danger  that  the 
inflammation  may  extend  itself  to  the  neighboring  tissue,  and  its  early 
origin  and  destructive  features  may  thus  be  concealed  in  the  signs  and 
sym{)toms  of  the  participating  parts.  Kesolution  of  these  foci  of  inflam- 
mation usually  occasions  a  localized  resorption  and  thinning  of  the  sclera, 
which  shows  itself  by  a  bluish  area,  that  may  subsequently  become  the 
seat  of  a  staphylomatous  projection. 

Gummy  infiltration  into  the  stroma  of  the  tissue  merely  differs  from  the 
episcleral  in  its  locality. 

The  following  case^  is  quoted  entire,  as  it  presents  so  complete  an  ex- 
ample of  the  way  in  which  gummy  formations  of  the  scleral  tissue  arise, 
progress,  and  terminate,  both  clinically  and  microscopically : — 

The  patient  was  a  Avell-developed  woman  of  thirty  years  of  age,  and 
at  the  time  of  the  attack  was  apparently  in  perfect  health,  and  without  the 
slightest  signs  of  a  syphilitic  cachexia.  Five  years  before,  she  had  had  a 
chancre,  for  which  she  had  been  treated  in  the  regular  way.  The  primary 
lesion  was  followed  by  the  usual  secondary,  and  these  in  their  turn  by  the 
so-called  tertiary,  symptoms. 

Three  years  after  inoculation,  and  two  years  before  the  present  trouble, 
the  patient  suffered  from  an  attack  of  iritis  in  both  eyes,  and  they  had 
remained  "  weak"  ever  since. 

The  present  attack  Avas  ushered  in  by  similar  symptoms,  and  the  belief 
on  the  part  of  her  attending  physician  was  that  the  patient  was  suffering 
from  a  second  attack  of  iritis.  The  trouble  was,  however,  confined  entirely 
to  the  left  eye.  The  injection  of  this  eye  gradually  increased  for  about  a 
week  or  ten  days,  unaccompanied,  however,  by  much  pain  or  loss  of  vision. 
The  patient  was,  however,  shortly  after  awakened  at  night  by  a  sudden 
and  very  violent  attack  of  pain,  with  a  very  rapid  loss  of  sight,  which  in 
a  day  or  two  resulted  in  total  blindness.  Becoming  alarmed,  the  patient 
presented  herself  at  the  Eye  and  Ear  Infirmary,  where  I  saw  her  for  the 
first  time,  about  two  weeks  after  the  beginning  of  the  attack. 

The  right  eye  at  this  time  appeared  to  be  perfectly  normal  in  every 
respect.  The  left  was  very  much  injected,  and  the  conjunctiva,  besides 
being  very  much  inflamed,  seemed,  in  conjunction  with  the  sub-conjunctival 
tissue,  to  be  thickened  and  oedematous,  especially  to  the  outer  side  of  the 
eye.  The  anterior  chamber  was  filled  by  a  yellowish  exudation,  so  that 
the  iris  was  concealed  from  view.  The  cornea  was,  however,  free  from 
any  ulcerative  process,  and  the  epithelial  layer  was  intact.  There  was  no 
perception  of  light. 

>  E.  G.  LoRiNG  and  H.  C.  Eno,  Trans.  Anier.  Ophth.  Soc,  1874,  p.  174. 


SYPHILITIC    AFFECTIONS    OF    THE    SCLERA.  705 

As  the  patient  was  suffering  violent  pain  in  and  around  the  eye,  and  as 
slie  would  not  permit  the  eye  to  be  removed  without  the  consent  of  her 
friends,  it  was  decided  to  do  a  free  paracentesis.  This  was  done  with  a 
Graefe's  knife,  a  free  incision  being  made  in  the  lower  margin  of  the  cornea. 
The  anterior  chamber  was  thoroughly  evacuated.  This  was  followed  by 
a  great  relief  of  pain. 

The  wound,  however,  gradually  closed,  and  with  its  closure  the  pain 
returned,  and  the  exudation  began  to  reappear  in  the  anterior  chamber. 
The  other  eye  (the  riglit),  which  up  to  that  time  had  sliown  no  trace  of 
any  trouble,  began  now  to  be  somewhat  sensitive  to  light,  and  to  show 
other  symptoms  which  seemed  to  be  of  a  sympathetic  nature.  Enucleation 
was  therefore  performed,  and  the  eye  given  to  Dr.  Elno,  whose  description 
of  the  examination  will  be  found  below. 

The  enucleation  of  the  left  was  followed  by  an  amelioration  of  the  con- 
dition of  the  right  eye,  so  far  as  the  dread  of  light  was  concerned ;  but  four 
days  after  the  operation  a  small  circumscribed  elevation  began  to  make 
itself  apparent  in  the  line  of  the  insertion  of  the  rectus  externus,  but  some- 
what closer  to  the  cornea.  Tliis  had  the  appearance  of  a  circumscribed 
elevation  of  the  sub-conjunctival  tissue,  the  conjunctiva  proper  being  but 
slightly  injected  just  over  it.  This  injection  of  the  conjunctiva  proper 
gradually  increased,  following  the  line  of  the  rectus  externus  muscle,  till, 
within  two  or  three  days,  it  had  spread  out  in  a  fan-  or  cone-like  shape, 
the  base  of  which  was  toward  the  external  canthus,  and  the  apex,  sharply 
defined,  towards  the  cornea. 

At  this  time  a  serous  exudation  underneath  the  conjunctiva  began  to 
make  its  appearance,  being  limited  to  the  external  and  lower  part  of  the 
eye.  The  injection  of  the  eyeball  gradually  extended  round  the  cornea, 
above  and  below,  till  it  had  included  the  whole  eye.  Still,  the  region  over 
and  around  the  tendon  of  the  externus  was  the  seat  of  the  most  marked 
symptoms  of  the  trouble,  and  from  the  serous  exudation  it  was  supposed 
that  something  was  interfering  with  the  circulation  of  both  the  superficial 
and  deeper  parts  of  this  portion  of  the  eye.  At  this  time  a  grayish,  spongy 
exudation  began  to  be  apparent  over  that  part  of  the  iris  opposite  the 
insertion  of  the  externus  rectus.  This  extended  itself  pretty  rapidly  in  a 
circuit  round  the  upper  portion  of  tlie  iris,  so  that  on  the  day  after  it  had 
been  first  noticed  tlie  exudation  had  extended  over  about  two-thirds  of  the 
entire  membrane,  leaving  the  outer  and  lower  parts  unaffected.  This 
exudation  had  a  very  peculiar  appearance,  looking  more  like  mould  of  a 
grayish-yellow  color  tlian  anything  I  can  compare  it  to.  It  projected  over 
the  edge  of  the  iris  into  the  pupillary  space  ;  and  vision,  which  had  liitherto 
remained  good,  now  sank  ra])idly,  so  that  the  ])atient  could  barely  count 
fingers  at  four  feet.  On  the  following  day  this  semi-transparent  exudation 
had  extended  all  round  the  iris  and  was  occupying  the  greater  part  of  the 
anterior  chamber.  Through  it  the  iris  could  be  dimly  seen,  of  a  dull 
velvety  hue.  Vision  was  so  bad  that  fingers  could  be  barely  counted  at  a 
foot  and  a  half,  Tlie  pupil  was  contracted,  though  not  markedly  so,  and 
there  were  no  adhesions  to  the  lens,  as  was  afterwards  shown  by  th(;  free 
dilatation  of  the  pupil  under  atropine.  Specific  treatment  had  from  the 
first  been  pushed  vigorously  witiiout  a[)i)arently  checking  the  jjiogress  of 
tlie  disease,  and  great  fears  were  entertained  that  the  eye  would  i'ollow  in 
the  s.inie  course  as  its  fellow. 

On  the  following  day,  however,  the  exudation  began  to  be  absorbed,  and 
disappeared  so  rapidly  that  within  thirty-six  hours  after  its  commencement 
45 


706  AFFECTIONS    OF    THE    EYES. 

the  anterior  chamber  was  entirely  free  from  it.     Vision  immediately  rose 
and  the  eye  made  a  steady  and  ra[)id  recovery. 

The  left  eye  was  phiced  in  jMiiller's  fluid  immediately  after  enucleation. 
The  eyeball  appeared  normal  in  size  and  shape,  with  the  exception  of  a 
very  considerable  tliickening  of  the  episcleral  tissue  at  the  outer  side  of 
the  cornea,  and  over  the  insertion  of  the  rectus  externus.  The  cornea 
was  o[)aque,  and  there  was  a  large  cicatrix,  the  result  of  the  previous 
opening,  in  the  lower  portion  of  it.  At  tlie  end  of  two  weeks  the  eye  was 
removed  from  INIiiller's  fluid,  and  opened  by  a  section  passing  nearly  through 
its  horizontal  meridian.  The  antero-posterior  diameter  of  the  eye  meas- 
ured 2G  mm.,  the  transverse  diameter  25  mm.  As  seen  in  this  section, 
the  episcleral  tumor  above  mentioned  is  about  1^  mm.  in  thickness,  and 
extends  back  nearly  to  the  equator  of  the  eyeball,  inclosing  in  its  substance 
tlie  tendon  of  the  rectus  externus.  Tiie  anterior  cliamber  is  fllled  with  a 
mass  of  yellow  exudation  completely  blocking  up  tlie  pupil.  Tlie  iris  and 
ciliary  body  are  enormously  increased  in  size,  but  es|)ecially  at  the  outer 
poi-tion  of  the  eye  corresponding  to  the  external  swelling;  here  the  iris 
measures  1-^^  mm.,  and  the  ciliary  body  3—4  mm.  in  thickness;  here  also 
the  substance  of  the  iris  and  ciliary  body  seems  to  be  continuous  witli  tlie 
mass  of  exudation  in  the  anterior  cliamber,  the  ligamentum  pectinatum 
ii'idis  being  broken  through.  The  ciliary  tumor  is  of  quite  Arm  consist- 
ence and  yellowish  in  color.  It  extends  backwards  to  tiie  region  of  the 
ora  serrata,  where  it  gradually  is  lost  in  the  choroid,  which  appears  to  be 
but  slightly  increased  in  thickness. 

The  lens  is  ti'ansparent  and  normal  in  appearance,  but  pushed  over 
to  the  nasal  side  by  the   swelling  of  the  ciliary  body  on  the  opposite  side 
of  the  eye.     The  vitreous  is  cloudy.     The  retina  and 
Fio-.  131.  choroid  are  in  place.     The  sclera  is  normal  in  appear- 

ance, and  may  be  seen  as  a  white  band  separating  the 
intra-  from  the  extra-ocular  tumor.      (Fig.  131.) 

Microscopic  examination  shows  that  tiie  episcleral 
tumor  is  due  to  an  inlihration  of  the  episcleral  tissue, 
with  a  multitude  of  round  cells.  The  cells  are  dis- 
tributed between  the  fibres  of  the  connective  tissue, 
and  the  bloodvessels  of  this  region  are  enlarged  and 
engorged. 

Section  of  eyeball.  At  the  limbus  a  Collection  of  cells  is  so  disposed  as 

Natural  Kize.  to  Separate  the  lam.  elast.  ant.  with  the  superjacent 

epithelium  from  the  corneal  tissue  for  a  considerable 
distance.  The  rest  of  the  cornea  presents  the  appearances  of  moderate 
keratitis.  The  anterior  chamber  is  filled  with  a  mass  composed  of  round 
cells  and  coagulated  fibrine.  The  outer  layers  of  the  sclera  are  invaded 
by  the  cell-growth,  and  throughout  its  whole  thickness  collections  of  round 
cells  may  be  seen  lying  between  the  bundles  of  fibrous  tissue. 

Thin  meridional  sections  were  made  through  the  centre  of  the  ciliary 
tumor,  and  the  iris  and  ciliary  body  were  found  to  be  infiltrated  with  a 
great  quantity  of  the  same  small  round  cells  as  exist  in  the  episcleral 
tumor.     (Fig.  132.) 

In  tiiat  portion  of  the  ciliary  body  near  the  sclera,  the  cells  are  distri- 
buted between  the  bundles  of  muscular  fibres  ;  and  as  we  pass  toward  the 
inner  surface  of  the  ciliary  body,  they  become  more  numerous,  separating 
the  muscular  bundles  more  and  more  widely,  until,  at  the  inner  margin, 
we  can  distinguish  only   a  mass  of  cells   thickly  packed  together  and  tra- 


SYPHILITIC    AFFECTIONS    OF    THE    SCLERA. 


707 


versed  by  an  oocasioiical  capillary  vessel.  These  cells  are  identical  in 
appearance  with  the  so-called  exudation,  or  lymphoid  cells,  being  about 
the  size  of  a  \shite  blood-corpuscle  and  containing  a  granular  nucleus.  In 
no  portion  of  the  tumor  do  they  present  the  appearances  of  granular  or 
fatty  degeneration. 


Fig.  T32. 


cdip,-^ 


Section  through  ciliary  region,  showing  ciliary  tumor  and  episcleral  tumor,  etc. 


In  the  iris  the  cells  are  very  abundant,  and  in  those  portions  most  af- 
fected it  is  scarcely  possible  to  recognize  any  element  of  normal  iris  tissue, 
except  the  pigment.  Tlie  inner  and  under  surface  of  the  ciliary  body  and 
iris  are  also  thickly  covered  with  masses  of  round  cells.  The  vitreous  is 
filled  with  round  cells  and  coagulated  fibrine. 

The  retina  and  clioroid  of  the  posterior  portion  of  the  eye  were  exam- 
ined, but  ]>resented  no  imusual  api)earances  beyond  those  of  an  inflamma- 
tory condition. 

In  view  of  the  clinical  history  and  pathological  api)earances  of  this  case 
it  must  be  regarded  as  one  not  merely  of  irido-cyclitis  syphilitica,  but  also 
of  syphilitic  gumma  of  the  ciliary  body  and  iris.  For  tliough  the  lesions 
do  not  differ  essentially  in  kind  from  those  of  a  simple  inflammatory  origin, 
still  their  intensity  and  circumscribed  character  together  witli  the  forma- 
tion of  a  distinct  tumor  justify  the  name  gumina,  notwithstanding  the  ab- 
sence of  retrogressive  metamorphosis. 

The  observations  of  three  similar  cases  have  been  recorded,  one  by  Von 
Hippel  (Graefe's  A.  f.  O.  viii,  p.  2SH),  two  by  F.  Ddalield  (Transactions 
of  the  Ophthalmological  Society,  1871)  ;  but  in  all  tiiese  cases  the  disease 
was  more  advanced  and  the  changes  more  extensive,  involving  all  the  tis- 
sues of  the  eyeball. 


708  affections  of  the  eyes, 

Syphilitic  Iritis. 

Of  all  the  affections  of  the  eye  there  is  none  which,  taken  as  a  whole,  is 
more  serious  in  its  immediate  effects,  or  more  disastrous  in  its  subsequent 
results,  than  iritis. 

It  is  estimated  from  carefully  prepared  statistics,  that  over  one-fourth  of 
the  cases  of  total  blindness  proceed  directly  from  inflamniation  of  tliis 
membrane,  and  when  it  is  taken  into  consideration  that  between  sixty  and 
seventy^  per  cent,  of  all  cases  of  iritis  are  due  to  syphilitic  infection,  the 
important  role  which  the  specific  virus  plays  in  this  class  of  diseases  be- 
comes at  once  manifest,  and  strongly  em[)hasizes  the  fact,  that,  since  the 
integrity  of  one  of  the  most  important  organs  of  the  human  frame  is  in- 
volved, syphilitic  iritis  should  be  familiar  to  every  student  of  venereal, 
in  order  that  he  may  early  be  able  to  recognize  and  treat  it. 

Let  me  premise  by  saying  that  we  have  no  certain  means  of  distinguish- 
ing syphilitic  iritis  from  that  dependent  upon  injury,  rheumatism,  or  other 
causes ;  although  there  are  certain  symptoms,  presently  to  be  described, 
which,  when  observed,  render  the  former  origin  probable.  Moreover,  the 
majority  of  cases  of  iritis  are  doubtless  due  to  syphilitic  taint,  so  that  the 
existence  of  this  disease  should  always  excite  suspicion,  and  lead  the  sur- 
geon to  make  a  thorough  examination  of  the  present  conditjon  and  past 
history  of  the  patient. 

In  accordance  with  the  teachings  of  pathological  anatomy  modern  ophthal- 
mologists have  divided  inflammation  of  the  iris  in  general  into  three  classes. 

(1)  Simple  or  plastic  ii'itis. 

(2)  Serous  iritis. 

(3)  Parenchymatous  or  suppurative  iritis. 

It  is  to  this  last  division  that  the  so-called  syphilitic  iritis  as  a  rule  be- 
longs ;  still,  as  the  disease  may,  and  often  does,  assume  either  of  the  above 
forms,  a  short  description  of  each  will  be  given,  omitting  the  more  minute 
details  which  are  chiefly  of  interest  to  the  ophthalmologist,  and  which  are 
apt  to  confuse  the  mind  of  one  who  has  not  made  a  special  study  of  the  eye. 

Simple  or  Plastic  Iritis This   form  is   characterized  by  congestion  of 

the  membrane,  but  differs  from  simple  hypera^mia  of  the  iris  by  tiie  pro- 
duction of  an  exudation  either  from  the  pupillary  border,  surface,  or  stroma, 
of  the  iris,  and  in  some  cases  by  an  increase  in  the  elements  of  the  connec- 
tive tissue. 

This  variety  of  the  disease  may  assume  a  very  mild  character,  present- 
ing but  a  very  moderate  degree  of  subconjunctival  injection,  and  accom- 
panied with  but  little  discoloration  of  th(,'  iris,  pain,  or  dread  of  light. 
Indeed,  it  may  happen  tliat  the  entire  trouble  escapes  detection  till  the  use 
of  atropine  brings  to  light  the  existence  of  one  or  more  adliesions  of  the 

'  My  friend,  Dr.  Henry  D.  Noyes,  of  the  Infirmary,  informs  me  that,  according 
to  statistics  collected  and  reported  in  his  lectures  by  Prof.  Graefe,  about  sixty  per 
cent,  of  all  cases  of  iritis  occur  in  persons  affected  with  syphilis.  See  also  Wecker, 
Etudes  ophthal.,  tome  i,  p.  394. 


8YPHILITIC    IRITIS.  709 

iris  to  the  anterior  capsule  of  the  lens,  producing  under  dilatation  the  char- 
acteristic irregularity  of  the  pupil. 

More  frequently,  however,  there  is  injection  of  the  conjunctival  and 
sclerotic  vessels,  giving  the  eye  a  red  appearance.  But  unnatural  redness 
is  observed  in  simple  conjunctivitis  ;  and  how  shall  the  two  be  distinguished? 
In  the  first  place,  by  depressing  the  lower  lid,  and,  at  the  same  time,  tell- 
ing the  patient  to  look  upwards  ;  whereby  the  inferior  palpebral  fold  will 
be  exposed.  In  most  cases  of  conjunctivitis,  the  greatest  amount  of  injec- 
tion will  be  found  remote  from  the  cornea ;  while  in  iritis  the  contrary  is 
the  case ;  the  redness  is  almost  entirely  confined  to  a  circle  round  the 
cornea,  called  the  "sclerotic  zone,"  and  the  more  distant  portions  of  the 
white  of  the  eye  remain  clear.  If  the  eye  has  been  congested  by  the  inju- 
dicious application  of  poultices,  alum  curds,  etc.,  this  difference  will  be  less 
or  not  at  all  apparent.  Again,  observe  the  character  of  the  injection  :  some 
of  the  conjunctival  vessels  are  distended,  and  may  be  recognized  by  their 
brick-red  color,  large  size,  tortuous  course  (chiefly  over  the  i-ecti  muscles), 
and  their  mobility,  if  the  conjunctiva,  by  means  of  slight  pressure  with  the 
finger  external  to  the  lid,  be  made  to  slide  over  the  sclerotica  ;  but  beneath 
these  brick-red  vessels  a  second  layer  is  discovered  on  close  examination, 
composed  of  others  radiating  from  the  margin  of  the  cornea,  much  finer 
than  the  preceding,  straight,  and  of  a  pinkish  hue,  and  which  are  seen  to 
remain  stationary  through  the  meshes  of  the  sliding  network  of  conjunc- 
tival vessels.  It  is  these  vessels  which  constitute  the  sclerotic  zone,  met 
with  not  only  in  iritis,  but  in  other  internal  inflammations  of  the  eye. 

Next  observe  the  condition  of  the  iris  and  pupil,  and  compare  them 
with  those  of  the  opposite  and  sound  eye.  The  affected  iris  is  seen  to 
have  lost  its  natural  brilliancy  ;  its  minute  texture  is  less  apparent ;  its  sur- 
face covered  over  with  a  tliin  layer  of  fibrin  ;  and  its  color  changed.  In 
persons  with  blue  eyes  it  assumes  a  yellowish-green  hue  ;  in  others,  the 
change  is  less  marked  but  may  generally  be  detected.  Close  the  two  eyes 
with  the  thumb  of  each  hand,  the  fingers  resting  for  support  upon  the  tem- 
ples, and  alternately  open  one  and  then  the  other  ;  and  the  iris  of  the 
affected  eye  will  be  found  to  be  sluggish  in  its  motions  or  quite  immovable. 

At  an  early  stage  of  the  disease,  the  pupil  assumes  a  dull  appearance, 
and  is  less  clear  and  bright  than  in  tlie  normal  condition,  owing  sometimes 
to  a  slight  turbidity  in  tlie  aqueous,  and  sometimes  to  a  delicate  film  of 
exudation  from  the  margin  of  the  iris  over  the  anterior  cajisule.  I  have, 
moreover,  sometimes  tliought  that  the  capsule  itself  or  the  underlying  epi- 
thelial cell  layer  became  implicated,  though  of  this,  so  far,  I  have  had  no 
anatomical  proof.  Tiie  pupil  may  also  become  irregular  in  shape.  This 
irregularity  of  outline,  due  to  adliesions  between  its  margin  and  the  capsule 
of  the  lens  or  to  exudation  into  its  substance,  becomes  more  marked  as  the 
disease  progresses,  and  is  especially  evident  if  the  pu[)il  be  dilated  by  bella- 
donna or  atropine,  when  its  margin  is  found  to  be  scalloped,  owing  to  its 
being  attached  at  some  points  and  drawn  out  in  others.  In  some  cases 
the  adhesions  become  continuous  around  the  whole  circumf«'rence,  and  tlie 
capsule  of  the  lens  is  covered  with  a  layer  of  lym[>h  which  couiiilctciy  blocks 
up  tlie  pupil. 


710  AFFECTIONS    OF    THE    EYES. 

Serous  Iritis. — This  is  distinguislied  from  tlie  simple  variety  by  the  fact 
that  the  exudation  is  of  a  serous,  instead  of  a  plastic  nature,  and  is  due  to 
a  hypersecretion  of  slightly  turbid  aqueous  humor,  which  produces,  as  a 
rule,  an  increase  in  the  intraocular  tension. 

On  this  account  the  anterior  chamber  becomes  deepened,  and  the  pupil, 
instead  of  being  contracted,  moderately  dilated,  sometimes  markedly  so. 
This  is  probably  due  to  direct  pressure  by  the  contents  of  the  globe  upon 
the  nerves  of  the  iris. 

The  circumcorneal  injection  is  here  much  less  than  in  the  plastic  form, 
or  it  may  be  entirely  wanting.  Besides  the  aqueous  humor  becoming 
slightly  cloudy,  the  entire  posterior  surface  of  the  cornea  appears  often- 
times as  if  covered  with  a  delicate  film,  and  minute  punctated  opacities 
make  their  appearances  upon  the  internal  lining  membrane  (membrane  of 
Descemet).  These  spots  owe  their  existence,  at  least  in  the  beginning  of 
the  disease,  to  the  precipitation  upon  the  membrane  of  minute  particles 
which  are  held  in  suspension  in  the  troubled  aqueous  humor,  and  which 
often  disappear  when  the  anterior  chamber  is  evacuated  by  pai'acentesis 
corneaj.  Later  in  the  disease,  however,  they  assume  a  somewhat  larger, 
size,  and  are  then  permanent,  being  due  to  a  morbid  change  in  the  epithe- 
lium of  the  membrane  itself.  , 

Sometimes  these  punctated  spots  are  either  entirely  absent  or  are  so 
slight  as  to  escape  any  but  a  most  careful  examination.  In  this  case  the 
predominant  symptoms,  viz.,  slight  discoloration,  and  dilatation  of  the  iris, 
and  trifling  cloudiness  of  the  aqueous  humor,  are  very  easily  overlooked  by 
an  inattentive  observer,  and  the  disease  is  allowed  to  progress  until  it 
extends  itself  to  the  ciliary  body  and  choroid,  gradually  involving  the 
deeper  structures,  and  the  eye  falls  step  by  step  into  a  state  of  low  chronic 
glaucoma. 

In  this  form  of  iritis  it  seldom  happens  that  there  are  any  adhesions  of 
the  iris  to  the  ca|)sule  of  the  lens. 

I  have  been  particular  in  giving  the  principal  symptoms  of  this  peculiar 
form  of  iritis,  both  on  account  of  its  insidious  nature,  which  renders  it  so 
liable  to  escape  detection,  and  from  the  fact  that  it  has  been  alleged  to  be 
oftentimes  the  product  of  hereditary  syphilis. 

Parenchymatous  or  Suppurative  Iritis This  form  of  iritis  is  char- 
acterized by  a  deep-seated  inflammation,  affecting  the  stroma  of  the  iris, 
and  giving  rise  to  a  considerable  swelling  of  the  membrane,  and  causing 
an  increase  in  its  cellular  tissue  elements.  Owing  to  this  fact  the  surface 
of  the  iris  becomes  elevated  in  different  parts,  and  vessels,  sometimes  of 
considerable  size,  from  arrest  in  their  circulation,  make  their  appearance 
on  the  surface  of  the  membrane.  These  elevations  are  almost  entirely 
composed  of  cellular  tissue,  and  usually  contain  a  number  of  vessels  of 
new  formation. 

It  is  in  this  form  of  iritis  that  we  meet  most  frequently  with  extensive 
adhesions  between  the  margin  of  the  pupil  and  the  lens,  together  with  a 
comjdete  loss  of  contractility  of  the  iris,  and  when  these  adhesions  once 
take  place  they  are  far  more  obstinate  in  resisting  the  effect  of  atropine 


SYPHILITIC    IRITIS.  711 

than  those  of  simple  idiopathic  iritis.  Here,  too,  the  production  of  pus 
in  the  anterior  chamber  is  much  more  rapid  and  abundant. 

The  so-called  syphilitic  iritis  of  various  authors  is,  strictly  speaking,  only 
a  variety  of  parenchymatous  iritis,  its  distinguishing  characteristic  being 
that  the  inflammatory  action  is  more  circumscribed,  confining  itself  usually 
to  one  part  of  the  iris,  Avhile  the  neighboring  portions  preserve,  for  a  con- 
siderable time,  at  least,  a  nearly  perfectly  normal  condition.  In  the  same 
way  it  is  less  apt  to  propagate  itself  to  the  deeper  lying  membranes.  It  is 
here  that  we  find  those  peculiar  brownish  or  yellowish  elevations  upon  tJie 
surface  of  the  iris,  which  generally,  though  not  always,  occur  on  its  inner 
ring  near  the  margin  of  the  pupil. 

These  "tubercles"  or  "condylomata,"  as  they  are  called,  gradually  in- 
crease in  size,  and  sometimes  become  organized  and  covered  with  a  net- 
work of  small  vessels.  They  vary  exceedingly  in  their  dimensions,  some- 
times acquiring  a  growth  sufiicient  to  occupy  the  quarter  or  even  one-half 
or  more  of  the  entire  iris,  and  if  then  situated  near  the  external  border  of 
the  membrane  they  may  cause  projection  of  the  cornea  or  sclerotic. 

It  has  been  demonstrated  by  Colberg^  that  the  composition  of  "tuber- 
cles" is  identical  with  that  of  gummy  tumors,  as  described  by  Virchow.' 

The  presence  of  these  tubercles  affords  a  very  strong  probability,  if  not 
an  absolute  certainty,  of  syphilitic  taint.  Of  sixty  cases  of  iritic  tubercle 
collected  by  Graefe,  in  only  two  was  there  no  proof  of  syphilitic  infection.* 

Such  evidence  as  this,  from  such  a  source,  must  be  considered  almost 
conclusive  that  there  is  a  specific  form  of  iritis  differing  from  that  of  the 
idiopathic  form,  although  such  has  been  denied.  So  far  as  my  own 
personal  experience  goes,  I  have  never  seen  a  case  of  "  condyloma"  of  the 
iris  which  could  not  be  traced  to  a  syphilitic  source.  I  have,  however, 
seen  one  case  in  a  non-syphilitic  subject  which  might  have  been,  and, 
indeed  was,  taken  for  a  "tubercle."  The  trouble  began  and  continued  in 
its  course  precisely  like  a  "  tubercle,"  with  all  the  signs  and  symptoms  of 
iritis,  until  it  had  reached  a  certain  stage,  when  it  ruptured,  sending  out 
into  the  anterior  chamber  a  feathery,  purulent  exudation,  like  the  tail  of 
a  comet.  After  a  careful  consideration  and  observation  of  the  case,  I 
could  attribute  the  appearances  only  to  a  papule  in  the  tissues  of  the  iris. 
Dr.  Kipp  has  also  reported  a  similar  case  in  a  syphilitic  person. 

When  syphilitic  iritis  is  early  and  successfully  treated,  the  iris  resumes 
its  normal  mobility  and  color,  and  the  eye  is  restored  to  its  original  in- 
tegrity. But  in  weak  and  cachectic  subjects  and  in  the  absence  of  appro- 
priate treatment,  the  changes  wliicii  take  place  are  more  or  less  permanent. 
The  tubercles  are  absorbed,  but  the  iris  never  regains  its  original  color 
and  consistency;  it  is  thinned  and  friable;  and  its  adhesions  to  the  cap- 
sule, unless  stretched  or  broken  by  the  persevering  use  of  mydriatics,  per- 
manently impede  the  motions  of  the  pupil.     As  a  general  rule,  the  pain 

'     '  ArchW  fiir  Oplith.,  t.  viii,  p.  288. 

2  Archiv  fiir  path.  Anat.,  No.  If),  p.  2(j5. 

3  Notes  of  Graefo's  Lectures,  for  wliioh  I  am  iudebtod  to  Dr.  Noyes. 


712  AFFECTIONS    OF    THE    EYES. 

and  pliotophobia  in  sypliilitic  iritis  are  much  less  than  in  the  other  forms 
of  the  disease.  The  patient  may  merely  complain  of  a  sense  of  fulness 
and  uneasiness  in  the  globe,  and  shrink  from  exposure  to  a  strong  light 
only.  In  other  cases,  severe  pain  is  felt  in  the  ball  of  the  eye  and  in  the 
temporal  and  supra-orbital  regions,  and  the  least  ray  of  light  causes  the 
most  intense  suffering;  the  variations  between  these  two  extremes  are 
numerous.  There  is  almost  invariably  some  dimness  of  vision  which  is 
due  not  only  to  the  changes  in  the  capsule  of  the  lens,  but  also  to  those  in 
the  deeper  structures  of  the  eye  which  are  always  involved  to  a  greater  or 
less  extent. 

Iritis  usually  presents  such  marked  symptoms  that  it  is  easily  recognized 
by  any  competent  person  ;  and  yet  every  ophthalmic  surgeon  must  have 
met  with  not  unfrequent  instances  in  which  through  carelessness  or  ignor- 
ance it  has  been  mistaken  for  simple  conjunctivitis  and  treated  solely  with 
coUyria  of  nitrate  of  silver,  sulphate  of  zinc,  etc.  A  few  cases,  however, 
are  met  with  in  which  the  most  experienced  surgeon  may  for  a  day  or  two 
fail  to  make  a  diagnosis.  This  generally  occurs  at  the  commencement  of 
the  disease,  before  any  marked  changes  have  taken  place  in  the  iris,  and 
especially  when  the  conjunctival  vessels  have  been  congested  by  the  ap- 
plication of  poultices.  Impairment  of  vision  will  afford  valuable  aid  to  the 
diagnosis,  and  the  instillation  of  a  drop  of  a  solution  of  atropine  will  soon 
decide  the  question,  by  showing  irregularity  of  the  pupil  if  the  case  be  one 
of  iritis. 

It  is  well  in  these  doubtful  cases  to  use  a  very  weak  solution,  as  then 
the  inconvenience  of  a  lengthy  mydriasis  is  avoided,  in  case  the  trouble 
should  prove  to  be  conjunctivitis  and  not  iritis.  One  of  Moore  and  Savory's 
atropine  wafers  divided  into  two  or  even  four  pieces,  each  piece  then  equal- 
ling only  ^oAoo  *^'^ '^  grain,  is  sufficient.  If  the  iris  is  not  the  seat  of  the 
trouble,  it  will  dilate  in  less  than  an  hour,  and  the  next  day  the  dilatation 
will  have  passed  off.  In  place  of  a  wafer,  a  solution  may  be  used  which 
can  be  readily  made  by  putting  one  drop  of  the  ordinary  solution  (gr.  ij  to 
^j)  into  half  an  ounce  of  water.     One  drop  of  this  equals  -gjy^-^o  of  a  grain. 

I  have  already  remarked  that  the  diagnosis  of  syphilitic  iritis,  although 
rendered  highly  probable  by  the  absence  of  severe  pain  and  photophobia, 
and  the  presence  of  tubercles  upon  the  iris,  can  only  be  satisfactorily  estab- 
lished by  the  history  of  the  case  or  the  coexistence  of  undoubted  syphilitic 
symptoms.  I  would  also  add  that  the  presence  of  any  general  eruption 
upon  the  body  leaves  scarcely  room  to  doubt  that  a  coexisting  iritis  is  of 
specific  origin,  since  this  disease,  when  due  to  other  causes,  is  very  rarely 
accompanied  by  affections  of  the  skin.  The  practical  surgeon,  when  called 
to  treat  a  case  of  iritis,  almost  instinctively  turns  to  the  arms,  chest,  and 
abdomen,  to  look  for  traces  of  one  of  the  syphilides,  to  the  throat  for 
mucous  patches,  and  to  the  neck  for  engorged  ganglia.  As  noticed  by 
Carmichael,  the  accompanying  eruption  is  in  most  cases  papular. 

In  regard  to  the  particular  period  of  the  general  trouble  in  which  specific 
iritis  makes  its  appearance,  no  precise  rule  can  be  laid  down  ;  still,  the 
form  which  is  most  common  and  most  worthy  of  our  attention  is  to  be 


SYPHILITIC    IRITIS.  713 

ranked  among  the  secondary  symptoms  of  syphilis.  Without  being  able 
to  furnish  any  statistics  from  which  the  exact  time  of  its  development  may 
be  determined,  yet  I  have  often  been  struck  with  the  fact  tliat,  when  no 
mercury  had  been  administered,  this  occurred  from  four  to  six  months 
after  contagion.  In  a  number  of  instances,  ii-itis  has  been  the  first  general 
symptom  which  has  induced  patients  to  seek  surgical  advice,  but  careful 
inquiry  has  never  failed  to  show  that  other  symptoms,  as  alopecia,  engorge- 
ment of  the  cervical  ganglia,  mucous  patches,  erythema,  or  papules,  had 
preceded  it,  although  regarded  at  the  time  as  of  no  importance. 

Wecker  observes^  that  thfe  specific  form  of  iritis  occurs  more  frequently 
when  the  disease  lias  been  a  long  time  in  developing  itself,  than  when  it 
has  pursued  a  rapid  course. 

There  is,  however,  another  form  of  iritis  which  is  met  with  chiefly  as  a 
symptom  of  tertiary  syphilis,  and  diflfers  from  the  preceding  mostly  by  the 
insidious  manner  in  which  it  attacks  the  eye,  and  by  its  greater  persis- 
tency. There  is  almost  a  complete  absence  of  pain  and  photophobia ;  the 
iris  becomes  infiltrated  and  covered  with  exudation  and  has  a  peculiar 
swollen  and  velvety  appearance  ;  numerous  adhesions  take  place  between 
its  pupillary  margin  and  the  capsule  of  the  lens ;  and  the  irregular  pupil  is 
blocked  up  with  an  effusion  of  lympli,  upon  which  small,  black,  uveal  de- 
])Osits  may  often  be  detected.  Both  eyes  are  generally  attacked  in  succes- 
sion ;  the  disease  is  exceedingly  persistent,  and  with  difficulty  controlled 
by  treatment ;  and  the  danger  of  complete  loss  of  sight  from  obstruction  of 
the  pupil  is  very  great.  The  deeper  structures  of  the  eye  appear  to  be 
implicated  to  a  less  extent  than  in  the  acute  form. 

Among  the  absurdities  of  medical  belief  tliat  have  h-ad  their  day  is  to  be 
reckoned  the  idea  that  mercury  may  give  rise  to  iritis — a  disease  which  is 
often  met  with  when  no  specific  remedy  has  been  employed,  and  which  can 
in  no  way  be  better  controlled  than  by  the  judicious  use  of  mercurials ; 
indeed,  the  surgeon  rarely  has  an  opportunity  of  witnessing  a  more  re- 
markable effect  of  treatment  than  is  seen  in  the  absorption  of  lymph,  the 
disappearance  of  the  abnormal  injection,  and  the  restoration  of  the  iris  to 
its  original  condition,  which  take  place  under  the  administration  of  mer- 
cury in  acute  syphilitic  iritis.  It  is  hardly  necessary  to  say  that  an  agent 
of  so  much  good  is  capable  of  doing  a  great  amount  of  harm,  and  that  I  am 
here  speaking  of  its  use  and  not  of  its  abuse. 

The  plan  of  treatment  of  the  acute  form  of  iritis  which  1  have  found 
almost  uniformly  successful,  has,  for  its  objects — 

1.  To  bring  the  system  under  the  influence  of  mercurials  as  speedily  as 
possible  without  injury  to  the  general  health,  and  without  inducing  sali- 
vation. 

2.  In  a  depressed  state  of  the  system,  to  combine  tonics  with  mercurials, 
or  to  employ  the  former  in  connection  Avith  iodide  of  ])olassium  instead  of 
the  latter. 

3.  To  keep  the  |)U|)il  constantly  dilated  by  means  of  atropine,  and  thus 
prevent  adhesions  between  the  iris  and  capsule  of  tiie  lens. 

>  Etudes  oplitli.,  t.  1,  p.  394. 


714  AFFECTIONS    OF    THE    EYES. 

4.  To  relieve  pain  and  regulate  the  general  hygienic  management  of 
the  case. 

The  subjects  of  these  different  heads  will  be  somewhat  briefly  considered, 
in  view  of  the  fact  that  most  of  them  have  been  included  in  what  has  been 
said  of  the  general  treatment  of  syphilis. 

In  persons  of  a  foir  state  of  health,  no  form  of  mercurial  is  preferable 
to  the  ordinary  pill  of  calomel  and  opium  (one  grain  of  the  former  to  a 
quarter  or  half  a  grain  of  the  latter)  administered  three  times  a  day — an 
hour  after  meals.  When  the  general  condition  of  the  system  is  depressed, 
a  tonic  should  be  combined  with  the  mercurial ;  and  the  following  formula} 
are  very  serviceable,  especially  when  the  patients  are  of  the  poorer  class, 
and  under  unfavorable  hygienic  influences: — 

R.     Hydrargyi'i  cum  Creta,  gr.  ij        ...         112 

Quinije  Sulphat.,  gr.  j        |06 

M.    et  ft.  plv. 

IJ.     Hydrargyri  cum  Creta,  gr.  ij        .     .     .  ♦      12 

Quiuiffi  Sulphatis,  gr.  j 06 

Pulveris  Doveri,  gr.  iij 18 

M.    et  ft.  plv. 

The  latter  formula  containing  Dover's  powder  is  to  be  preferred  when 
the  pain  is  severe.  The  frequency  of  the  administration  of  these  powders 
is  to  be  determined  by  the  strength  and  general  condition  of  the  patient. 
Under  ordinary  circumstances,  one  may  be  given  three  times  a  day;  or, 
when  the  system  is  much  depressed,  one  morning  and  night,  with  one  or 
two  grains  of  quinine  in  addition  twice  during  the  day;  and  when  thus 
o-uarded  by  quinine,  mercury  may  be  employed  in  nearly  every  case  of 
this  disease.  It  is  well  to  prolong  the  use  of  this  remedy  until  evidence 
of  its  action  upon  the  mouth  is  perceptible,  but  not  to  continue  it  until 
salivation  is  produced.  So  soon  as  the  gums  are  in  the  slightest  degree 
affected,  the  mercurial  should  be  suspended,  and  chlorate  of  potash  em- 
ployed, while  at  the  same  time  the  tonic  may  be  continued. 

The  opposite  eye  will  sometimes  be  attacked  while  the  patient  is  taking 
mercury  for  the  one  first  affected,  and,  in  rare  instances,  even  during  the 
existence  of  ptyalism  ;  just  as  a  new  eruption  will  occasionally  appear  upon 
the  skin  while  undergoing  treatment  for  an  old  one. 

It  will  be  observed  that  the  above  mode  of  employing  mercury  in  com- 
bination with  quinine,  as  practised  for  many  years  at  the  New  York  Eye 
Infirmary,  is  widely  different  from  the  exclusive  use  of  this  mineral,  which 
has  been  recommended  by  some  authors.  It  would  be  out  of  place  in  the 
present  work  to  enter  into  a  discussion  of  the  comparative  merits  of  the 
two  methods,  and  I  must,  therefore,  content  myself  with  expressing  a 
strong  preference  for  the  one  here  proposed ;  merely  adding,  that  it  is 
equally  as  true  of  iritis,  as  of  other  syphilitic  manifestations,  that  the  ad- 
ministration of  mercury,  without  regard  to  the  condition  of  the  patient,  is 
quite  as  likely  to  do  harm  as  to  do  good. 

It  is  of  the  first  importance  in  the  treatment  of  iritis  to  maintain  the 
pupil  in  a  constant  state  of  dilatation,  so  as  to  remove  the  iris  as  far  as 


SYPHILITIC    IRITIS.  715 

possible  from  the  convex  surface  of  the  lens,  and  prevent  adhesions  or 
closure  of  the  pupil  with  ljmi)h.  For  this  purpose,  instillations  of  a  solu- 
tion of  atropine  are  far  preferable  to  extract  of  belladonna  smeared  upon 
the  brow.  In  addition  to  its  power  of  dilating  the  pupil,  atropine  is  a 
most  valuable  sedative — a  rare  combination  in  the  same  remedy.  Two 
grains  of  the  neutral  sulphate  to  the  ounce  of  distilled  water,  is  the  formula 
Avhich  I  commonly  employ.  This  solution  is  best  applied  to  the  inner 
canthus  by  means  of  an  eye-pipette  or  a  camel's-hair  brush  ;  in  default  of 
which,  the  patient's  head  may  be  thrown  back,  and  a  small  portion  of  the 
fluid  be  poured  upon  the  concavity  upon  the  side  of  the  nose,  when  some 
of  it  may  readily  be  made  to  flow  between  the  lids.  If  the  case  be  seen 
at  the  outset,  before  the  motions  of  the  iris  are  impeded  by  an  infiltration 
of  lymph,  two  or  three  times  a  day  will  be  sufficiently  often  to  use  the 
drops.  In  the  acute  stage  of  iritis,  some  authors  advise  us  entirely  to 
abstain  from  the  use  of  atropine  and  belladonna,  which  have  but  little 
power  of  influencing  the  pupil  after  effusion  has  taken  place,  and  which, 
it  is  said,  may  "irritate  and  tease  the  iris,  and  cause  pain."^  My  own 
experience  leads  me  to  believe  that  these  fears  are  groundless.  Instead 
of  aggravating,  I  believe  that  atropine  greatly  relieves,  the  pain  and  irri- 
tation, and  although  its  immediate  action  upon  the  pupil  is  not  perceptible, 
yet  it  gradually  stretches  or  breaks  down  the  adiiesions  already  formed, 
and  thus  assists  the  iris  in  recovering  its  dilatability ;  hence  I  am  in  the 
habit  of  increasing  the  frequency  of  the  instillations,  during  the  acute 
stage,  to  three  or  four  times  a  day,  and  in  case  the  iris  is  still  obstinate  in 
yielding,  it  is  advisable  to  increase  the  strength  of  the  solution  to  four  or 
five  grains  to  the  ounce  of  water,  and  to  instil  a  drop  into  the  eye  every 
five  minutes  for  twenty  minutes  or  half  an  hour  at  a  time,  repeating  this 
method  of  application  three  or  four  times  a  day.  Care  should  be  taken, 
however,  that  the  atropine,  some  of  which  gains  the  pharynx  through  the 
lachrymal  and  nasal  passages,  does  not  produce  its  physiological  effects 
upon  the  general  system. 

Very  recently  a  new  mydriatic,  Duboisine,  has  come  into  use.  It  has 
the  same  effect  as  atropine,  though  it  is  somewhat  more  powerful.  It  is 
claimed  that  it  is  less  apt  to  produce  the  poisoning  of  tlie  circumorbital 
skin,  and  that  it  may  be  used  when  this  has  been  occasioned  by  atropine. 
My  own  experience  wiUi  it,  however,  does  not  support  this  claim,  for,  in 
several  instances,  when  the  poisoning  had  been  once  produced,  it  was 
maintained  by  Duboisine  just  as  it  is  by  atropine.  It  is  well,  however, 
in  those  cases  which  promise  to  be  protracted,  to  use  the  drugs  alternately. 

Siiould  the  iris  refuse  to  yield  even  after  this  vigorous  use  of  atropine, 
the  action  of  the  drug  can  often  be  induced  by  decreasing  the  tension  of 
the  eye,  through  the  application  of  leeches  to  the  temple,  or  by  the  evacua- 
tion of  the  anterior  chamber  by  paracentesis  corneas. 

Venesection  is  never  required  in  syphilitic  iritis,  though  local  de|)letion 
by  means  of  cups  and  leeches   is  often  advisable  in   those   cases  in  robust 

'  Critchett,  Lectures  on  Diseases  of  the  Eye,  Jjondon  Lancet,  Am.  etl.,  March, 
1855,  p.  216. 


71G  AFFECTIONS    OF    THE    EYES. 

subjects,  where  tiie  pain  is  very  severe  ;  and  when  this  assumes  a  neuralgic 
character,  frequent  fomentation  of  the  eye  and  surrounding  parts  with 
water,  as  hot  as  can  be  borne,  often  gives  great  relief.  Here,  too,  a  subcu- 
taneous injection  of  morphia  in  the  region  of  the  temple  often  stops  at  once 
a  paroxysm  of  pain  which  then  does  not  show  itself  again,  or  at  least  not 
in  its  former  violence.  After  the  acute  stage  has  passed,  counter-irrita- 
tion may  be  effected  by  painting  the  brow  with  the  strong  tincture  of 
iodine.     This  remedy  is,  however,  not  as  much  employed  as  formerly. 

It  is  highly  important  that  the  patient  should  obtain  sleep,  for  which 
purpose  ten  grains  of  Dover's  powder  may  be  given  at  bedtime,  and  re- 
peated if  necessary.  In  many  cases,  however,  frictions  upon  the  brow  and 
temple  at  bedtime  of  mercurial  ointment,  with  the  addition  of  powdered 
opium  (ung.  hydrarg.  ^j,  pi  v.  opii  5j)  ^^ill  suffice  to  allay  pain  and  pro- 
cure sleep. 

In  this,  as  in  nearly  all  affections  of  the  eye,  the  surgeon  has  to  contend 
with  the  deeply-rooted  prejudices  of  the  masses  in  favor  of  poultices  of 
bread  and  milk,  tea  leaves,  alum  curds,  raw  oysters,  pieces  of  pork,  et  id 
genus  ornne.  Not  only  should  all  such  vile  applications  be  put  far  away, 
but  the  eye  should  not  be  tied  up  with  handkerchiefs  or  cloths  in  any 
manner.  In  women,  the  best  protection  against  the  strong  light  is  a  veil; 
in  men,  a  pasteboard  shade  will  answer  the  same  purpose. 

In  unfavorable  weather,  or  in  unusually  severe  cases  of  iritis,  the  patient 
should  be  confined  to  the  house,  or  even  to  his  room,  which  should  be 
shaded  but  not  darkened.  In  most  cases,  however,  when  the  weatlier  is 
fair,  it  is  desirable  that  the  patient  should  pass  a  portion  of  the  day  out  of 
doors,  in  the  early  morning  or  evening,  if  the  intolerance  of  light  be  ex- 
cessive, and  with  the  eyes  protected  in  the  manner  above  directed,  or 
better  still,  by  a  pair  of  tinted  glasses  of  the  kind  which  is  known  at  the 
opticians'  as  "  coquilles,"  the  color  of  wdiich  should  be  some  shade  of  blue 
or  London  smoke,  never  green.  Photophobia  and  irritability  of  the  eye 
will  be  aggravated  by  confinement  to  a  dark  room. 

The  diet  must  be  proportioned  to  the  general  condition  of  the  system. 
Robust  subjects  should  take  but  a  small  quantity  of  light  food ;  while  the 
cachectic  require  an  abundant  supply  of  nourishment,  and,  it  may  be,  stimu- 
lants. Proper  attention  should  also  be  paid  to  the  digestive  organs,  and  a 
daily  evacuation  of  the  bowels  secured. 

The  chronic  form  of  iritis  met  with  in  tertiary  syphilis  most  frequently 
occurs  in  persons  whose  constitution  is  enfeebled,  and  by  whom  mercury  is 
poorly  tolerated ;  but  when  properly  guarded  by  tonics,  this  mineral  may 
still,  in  many  cases,  be  used  with  marked  benefit;  in  others  we  are  obliged 
to  resort  to  iodide  of  potassium,  until  by  every  available  means  the  general 
healtli  is  restored.  Mercurial  inunction  or  fumigation  may  often  be  em- 
ployed, Avhen  mercury  by  the  mouth  cannot  be  borne.  In  these  cases  one- 
half  or  even  a  drachm  of  the  oleate  may  be  rubbed  into  the  soles  of  the 
feet  alternately,  or  under  the  armpits  each  night. 

Such  being  the  therapeutical  remedies  which  experience  thus  far  has 
shown  us  to  be  the  most  beneficial  in  the  treatment  of  syphilitic  iritis,  two 


SYPHILITIC    IRITIS.  717 

others,  belonging  properly  to  the  domain  of  surgery,  ought  to  be  briefly 
considered,  or  at  least  mentioned,  here.  I  allude  to  paracentesis  cornete 
and  iridectomy. 

If  in  spite  of  all  our  efforts  at  medication  the  acpieous  humor  becomes 
very  cloudy,  or  the  pain  increases,  or  the  tension  of  the  eyeball  becomes 
augmented,  with  a  corresponding  decrease  of  the  amount  of  vision  and 
contraction  of  the  visual  field — or  if  a  considerable  collection  of  pus  takes 
place  into  the  anterior  chamber — then  a  paracentesis  should  be  performed 
and  repeated  several  times,  if  necessary  ;  and  especially  should  this  be 
done  in  the  last  mentioned  condition,  for  of  all  the  remedies  which  we 
possess  against  the  formation  and  increase  of  hypopyon  none  is  more  effica- 
cious than  this. 

Should,  however,  the  disease  still  steadily  progress,  and  the  above  symp- 
toms increase  in  severity,  and  give  evidence  that  the  inflammatory  action 
runs  in  danger  of  seriously  involving  the  deeper  structures  of  the  eye,  then 
an  iridectomy  should  be  performed  at  once,  for  it  often  happens  that  an 
inflammation  which  has  resisted  all  other  agents  cpiickly  subsides  after  this 
operation.     The  above  is  applicable  to  all  forms  of  iritis. 

For  a  more  detailed  description  of  these  two  operations,  as  well  as  of 
those  intended  for  the  relief  of  closure  of  the  pupil  from  the  effects  of  iritis, 
I  must  refer  the  reader  to  works  upon  Ophthalmic  Surgery,  merely  re- 
marking that  these  operations  require  considerable  delicacy  of  manipulation, 
and  if  the  general  practitioner  feels  that  he  does  not,  from  want  of  prac- 
tice, possess  the  requisite  technical  skill,  then  it  is  his  duty  to  obtain  the 
services  of  some  one  who  has  made  these  matters  a  special  study. 

Infantile  Iritis — An  extremely  interesting  form  of  iritis  is_  met 
with  in  infants  affected  with  hereditary  syphilis.  It  is  a  rare  disease,  but 
probably  exists  in  many  instances  in  which  it  is  overlooked. 

Mr.  Hutchinson  deduces  the  following  conclusions  from  a  series  of  21 
cases  : — ^ 

1.  That  the  subjects  of  infantile  iritis  are  much  more  frequently  of  the 
female  than  the  male  sex. 

2.  That  syphilitic  infants  are  most  liable  to  suffer  from  iritis  at  about 
the  age  of  five  months. 

3.  That  syphilitic  iritis  in  infants  is  often  symmetrical,  but  quite  as 
frequently  not  so. 

4.  That  iritis,  as  it  occurs  in  infants,  is  seldom  complicated,  and  is  at- 
tended by  but  few  of  the  more  severe  symptoms  which  characterize  the 
disease  in  the  adult.  Haziness  of  the  cornea  and  photophobia,  which  are 
common  in  adults,  are  rare  in  infants,  in  whom  there  is  also  but  little  paiu 
and  sclerotic  injection. 

.5.  Notwithstanding  the  ill-cliaracterized  phenomena  of  acute  inflamma- 
tion, the  effusion  of  lympii  is  usually  very  free,  and  the  danger  of  occlusion 
of  thf>  pupil  great. 

'  Med.  Times  and  Gaz.,  July  14,  18G0;  also  (3i)hthalinic  Hospital  Reports,  vol. 
viii,  p.  217,  1875. 


7J8  AFFECTIONS    OF    THE    EYES. 

6.  Mercurial  trentment  is  most  signally  efficacious  in  curing  the  disease, 
and,  if  recent,  in  procuring  the  complete  absorption  of  the  effused  lymph." 

7.  Mercurial  treatment  previously  adopted  does  not  prevent  the  occur- 
rence of  this  form  of  iritis. 

8.  Tlie  subjects  of  infantile  iritis,  though  often  puny  and  cachectic,  are 
also  often  apparently  in  good  health. 

9.  Infants  suffering  from  iritis  almost  always  show  one  or  another  of  the 
well-recognized  symptoms  of  hereditary  taint. 

10.  Most  of  those  who  suffer  from  syphilitic  iritis  are  infants  born  within 
a  short  period  of  the  date  of  the  primary  disease  in  their  ])arents.  This 
ii€cords  with  what  is  observed  in  the  iritis  of  adults,  which,  in  a  great 
majority  of  instances,  is  a  secondary  and  not  a  tertiary  symptom. 

I  have  seen  only  one  instance  of  this  affection  in  an  infant  at  the  Infir- 
mary, who  was  not  brought  a  second  time,  and  whose  case  I  was  therefore 
unable  to  follow  out.  I  once  had  under  my  charge  a  case  of  double  chronic 
iritis  in  a  boy  aged  10,  affected  also  with  engorgement  of  tiie  cervical  gan- 
glia, who,  as  reported  by  his  father,  was  said,  by  the  attending  physician 
(Dr.  G.  L.  Bedford),  to  have  contracted  syphilis  from  his  wet-nurse.  I 
may  mention  incidentally,  that  his  teeth  were  generally  misshapen,  and  that 
one  of  his  upper  incisors  was  completely  perforated  by  a  small  hole  about 
one-third  of  its  length  from  the  lower  margin. 

Spongy  Iritis. — Under  this  title  some  ophthalmologists  have  of  late 
years  described  a  form  of  iritis  which  consists  of  a  gelatinous,  spongy  exu- 
dation into  the  anterior  chamber  from  the  surface  of  the  iris.  This  has 
been  claimed  to  be  due  to  syphilis.  It  has  however  no  pathognomonic 
significance,  and  may  occur  in  the  idiopathic  form,  or  from  simple  trau- 
matism.^ The  manner  in  which  it  is  formed,  and  the  appearances  which  it 
presents,  have  already  been  described  at  length  in  speaking  of  episcleritis. 

Affections  of  the  Lens. 

So  far  the  lens  has  never  been  observed  to  be  primarily  the  seat  of  any 
syphilitic  inflammation  or  product.  Secondary  changes  in  the  capsule  and 
lenticular  substance,  in  which  the  lens  becomes  either  partially  or  wholly 
cataractous,  are  common  enough.  The  only  relief  from  tliese  is  surgical, 
and  may  consist  either  in  the  formation  of  a  new  pupil  or  in  extraction,  and 
I  am  inclined  to  believe  from  my  own  exjierience,  that  these  cases  of 
cataract  with  numerous  adhesions,  even  to  the  extent  of  total  synecliia,  do 
not  offer  so  bad  a  prognosis  as  is  commonly  supposed. 

Affections  of  the  Ciliahy  Body. 

Inflammations  of  the  ciliary  body,  or  cyclitis,  which  are  not  due  to  exten- 
sion of  the  morbid  process  from  the  iris  on  the  one  hand,  and  the  choroid 

'  Dr.  Gkueking,  Arcliiv  Ophth.  and  Otol.,  vol.  iii,  p.  1,  1873. 


CHOROIDITIS.  719 

on  the  other,  are  extremely  rare.  Syphilitic  cyclitis,  like  the  non-specific, 
sliows  itself  by  a  deep-lying,  partial  or  total,  pericorneal  injection  of  a  livid 
color,  which  is  usually  more  intense  in  one  particular  spot,  and,  as  a  rule, 
at  the  upper  portion,  though  it  may  be  in  any  part,  of  the  scleral  zone. 
Sometimes  more  than  one  of  these  foci  exist  at  the  same  time.  There  is 
usually  a  peculiar  retraction  of  the  iris  opposite  the  inflammatory  centre 
or  centres,  which  is  then  useful  as  a  diagnostic  mark  of  the  trouble  being 
limited  to  the  ciliary  body,  for,  if  the  iris  is  implicated,  the  contraction  of 
the  pupil  conceals  this  peculiarity  in  the  shape  of  the  iris.  Here,  as  else- 
Avhere  in  the  area!  tract,  the  only  distinctive  mark  of  the  syphilitic  taint  is 
the  characteristic  gummata.  The  manner  in  which  these  are  formed  has 
already  been  detailed  with  a  drawing  of  the  microscopical  appearances, 
under  the  subject  of  Episcleritis,  and  need  not  be  dwelt  on  further  in  this 
place.  The  diagnosis  of  these  troubles  is  oftentimes  somewhat  speculative, 
as,  from  the  position  of  the  ciliary  body,  these  affections  do  not  lie  open  to 
either  direct  inspection  or  that  of  the  ophthalmoscope.  Virchow^  was 
however,  fortunate  enough  to  see  a  gummy  tumor  of  the  ciliary  body, 
which  ophthalmoscopically  and  by  oblique  light  was  seen  and  taken  by 
others  for  a  sarcoma.  That  syphilis  was  the  cause  of  the  tumor  was  de- 
monstrated by  the  fact  that  it  disappeared  under  specific  treatment. 

Choroiditis. 

Choroidal  affections,  like  those  of  the  iris,  have  been  divided  into  three 
principal  classes. 

(1)  Plastic  (exudativa,  disseminata)  choroiditis. 

(2)  Serous  choroiditis. 

(3)  Parenchymatous  (suppurative)  choroiditis. 

It  must  be  admitted  that  the  distinctions  between  these  various  forms 
cannot  be  drawn,  either  pathologically  or  clinically,  so  closely  as  those  of 
iritis;  still,  as  they  are  based  on  anatomical  research,  however  meagre, 
they  are  preferable  to  any  classification  of  a  merely  arbitrary  character, 
and  will,  therefore,  be  retained  here;  inasmuch  as  they  may  all  be  the 
l)roduct  of  sypliilitic  infection,  a  short  description  of  each  will  be  given. 

Plastic  choroiditis,  or  more  properly  speaking  choroiditis  exudativa,  is 
characterized  by  the  production  of  an  exudation  upon  the  surface  or  in 
the  substance  of  the  choroid.  This  exudation  manifests  itself,  when  seen 
by  the  o[)hthalmosco[)e,  by  the  presence  at  the  bottom  of  the  eye  of  certain 
circumscribed  spots  or  patches,  varying  greatly  as  to  number,  shape,  and 
size.  When  freshly  deposited  they  are  of  a  yellowish-white  or  pale  straw 
color,  and  give  the  appearance  of  having  been  flecked  on  to  the  membrane, 
the  pigment  epithelium  jn-eserving,  as  a  general  rule,  a  perfectly  normal 
aspect.  These  sj)ots  entirely  conceal  from  view  the  subjacent  choroid,  so 
tliat  the  epithelial  layer  together  with  the  deeper  lying  vascular  tunics  are 
conn)letely  hidden  from  sight;  while,  on  the  contrary,  the  retinal  vessels, 

•  Jahrcsbericht  der  Ophth.,  1872,  p.  307. 


720  AFFECTIONS    OF    THE    EYES. 

Avhich  as  a  rule  run  over  tlie  patclies  unimpeded  in  their  course,  are  brought 
strongly  in  view  through  contrast,  and  clearly  prove  the  trouble  to  be  in 
the  deeper  seated  membrane. 

These  spots  of  exudation  may  be  entirely  absorbed,  and  leave  but  little 
or  no  trace  of  their  former  existence,  but  usually  they  pass  to  a  secondary 
or  atrophic  stage,  in  which,  although  the  exudation  itself  disappears,  the 
underlviu"-  and  surrounding  tissue  becomes  implicated.  On  this  account 
the  substance  of  the  choroid  itself  undergoes  atrophic  changes,  permitting 
the  sclera,  on  account  of  the  former  becoming  thinned,  to  show  through ; 
thus  giving  to  what  were  formerly  straw-colored  spots  a  glistening  white 
appearance.  These  atrophic  spots  may  be  further  distinguished  from  those 
due  to  simple  exudation  by  the  fact  that  single  choroidal  vessels  or  their 
remains  may  be  detected  on  their  surface,  while  their  border,  instead  of 
being  sharply  defined  and  surrounded  by  normal-looking  tissue,  is  irregular, 
and  marked  by  collections  of  dark  pigment  cells  which  from  proliferation 
may  combine  together  so  as  to  form  a  black  zone,  which  then  surrounds 
in  part  or  in  whole  the  denuded  spots;  or  the  pigment  may  lie  irregularly 
scattered  over  its  surface.  This  latter  takes  place,  especially  in  the  early 
stage  of  the  disease,  when  the  trouble  is  confined  to  the  internal  and  pig- 
mentary layers,  producing  a  condition  known  as  "maceration  of  the  pig- 
ment of  the  choroid,"  in  which  the  coloring  matter  is  distributed  irregu- 
larly, thinned  in  some  places  and  aggregated  in  others,  thus  giving  to  the 
fundus  of  the  eye  a  mottled  or  watery  appearance,  as  if  sprinkled  with  ink. 

Serous  Choroiditis This  is  characterized  by  the  exudation  from  the 

choroidal  membrane  being  of  a  serous  instead  of  a  plastic  nature,  and  pre- 
sents externally  oftentimes  the  same  appearance,  both  as  to  the  dilatation 
of  the  pupil  and  spots  upon  the  inner  surface  of  the  cornea,  as  serous  iritis. 
The  ophthalmoscopic  appearances  are  not  well  marked,  and  are  some- 
times entirely  wanting.  When  present,  however,  they  are  sucli  as  are 
produced  by  increased  intraocular  pressure,  and  are  chiefly  confined  to 
the  pigment  epithelium,  the  whole  surface  of  which  may  be  affected,  ex 
hibiting  the  changes  peculiar  to  the  condition  of  "  maceration."  Some- 
times this  form  is  also  accompanied  by  extensive  changes  in  the  fundus, 
similar  to  those  just  detailed  under  the  plastic  form.  This  variety  is  ex- 
ceedingly prone  to  fall  into  a  glaucomatous  condition,  and  is  then  accom- 
panied by  excavation  of  the  optic  nerve  and  the  other  ophthalmoscopic 
signs  common  to  that  disease. 

Parenchymatous  Choroiditis This  is  a  deep-seated  inflammation  with 

a  marked  tendency  towards  an  increase  in  the  celluhir  tissue  elements, 
especially  in  the  neighborhood  of  the  larger  choroidal  vessels.  This  hyper- 
trophy of  the  cellular  tissue,  as  in  this  form  of  iritis,  sometimes  forms 
masses  which  are  elevated  considerably  above  the  surrounding  level  of  the 
choroid,  and  may  attain  the  size  and  api)eanince  of  a  veritiible  tumor  most 
probably  of  gummy  origin,  and  as  such  project  into  the  vitreous  humor, 
its  surface  being  covered  by  the  retina  which  ordinarily  undergoes  fatty 
degeneration. 

It  is  this  variety  of  the  affection  which  has  been  described  by  various 


CHOROIDITIS.  721 

authors  as  "  choroiditis  circumscripta,"  and  attributed  by  them  particularly 
to  a  syphilitic  origin. 

The  fact  is,  however,  that  the  predominant  cause  of  all  choroidal  affec- 
tions is  the  specific  virus,  and  the  particular  form  under  which  it  shows 
itself  most  frequently  is  certainly  the  plastic  form  (choroiditis  exudativa). 
There  are,  however,  even  in  this  latter  form,  certain  peculiarities  Avliich 
have  been  thought  by  some  of  the  leading  authorities  (Graefe,  Liebreich, 
Schweigger,  and  others)  to  be  characteristic  of  the  specific  origin  of  the 
disease.     The  chief  of  these  are  : — 

(1)  The  spots  of  exudation  and  atrophy  are,  as  a  rule,  situated  at  the 
posterior  pole  of  the  eye,  and  in  the  neighborhood  of  the  macula,  instead  of, 
as  in  the  idiopathic  variety,  at  the  periphery.  Tliey  also  have  a  tendency 
to  arrange  themselves  in  groups,  are  less  apt  to  coalesce  with  each  other, 
while  at  the  same  time  they  penetrate  deeper. 

(2)  The  retina  and  optic  nerve  are  more  apt  to  be  involved  and  some- 
times to  such  a  degree  as  to  undergo  subsequently  partial  or  complete 
atrophy. 

(3)  The  choroidal  affection  is  very  liable  to  be  complicated  with  a  char- 
acteristic disturbance  of  the  vitreous,  which  often  appears  and  disappears 
with  great  rapidity.  Oftentimes  this  opacity  is  so  delicate  as  to  give  the 
idea  of  a  slight  want  of  transparency  of  the  retina. 

1  must,  however,  guard  the  reader  against  placing  too  much  dependence 
on  the  above  statements  as  to  the  specific  origin  of  the  disease,  especially 
in  regard  to  the  situation  and  general  contour  of  the  patches,  as  these  are 
often  situated,  even  in  undoubted  cases  of  specific  infection,  at  the  very 
periphery  instead  of  the  posterior  ],x)le  of  the  eye,  and  may  assume,  what- 
ever their  seat,  any  and  all  shapes.  So,  too,  disturbance  of  the  vitreous 
humor  is  one  of  the  commonest  complications  of  all  choroidal  affections. 

It  would  be  out  of  place  in  a  w^ork  of  this  kind  to  give  a  detailed  descrip- 
tion of  all  tlie  opiithalmoscopic  appearances  wliich  this  protean  disease  may 
assume.  1  would,  therefore,  since  the  use  of  the  ophthalmoscoi)e  has  now 
become  so  prevalent,  and  opportunities  for  its  study  so  attainable,  strongly 
advise  the  student  of  venereal  diseases  to  make  himself  acquainted  at  least 
with  the  general  outlines  of  oplitlialmoscopy. 

It  is  only  in  this  way  that  he  can  get  at  all  an  adequate  idea  of  a  large 
class  of  diseases  which  are  intimately  connected  with  syphilis,  and  in  this 
connection  I  would  refer  the  reader  to  the  magnificent  plates  of  Jaeger,* 
Liebreich,^  and  Stellwag  von  Carion.^ 

If  the  connection  between  the  iris  and  choroid,  anatomically  speaking, 
is  an  intimate  one,  clinically  s[)eaking  it  is  even  more  so,  and  the  diseases 
of  the  one  may  be  considered  as  the  analogue  of  the  other  ;  for  this  reason 

'  jAF.r.EK,  Ophthahnoskopishclior  Handatlas,  1868.  Choroiditis  Exudativa, 
Tafcl  XXII,  figs.  99,  100;  Taf.  XXIII,  figs.  101,102,  104;  Taf.  XXIV,  XXVIII, 
XXIX-: 

2  LiKHKEicn,  Atlas  d'Ophthalmoscopie.  Choroiditis  Sypliilitica.  Table  IV, 
fig.  2.  (See  also  Soclberg  Wells,  for  copy  of  tiie  sauio.) 

s  Stellwag  vox  Carion.     American  edition. 
4G 


722  AFFECTIONS    OF    THE    EYES. 

the  indications  for  treatment  and  the  remedies  to  be  employed  are,  as  a 
rule,  precisely  the  same  as  those  laid  down  under  iritis,  only  greater  care 
and  attention  are,  it"  possible,  required  of  the  physician,  as  the  part  con- 
cerned is  hidden  from  ordinary  inspection. 

Choroiditis  syphilitica,  as  a  rule,  belongs  to  the  later  stages  of  life  in 
which  the  disposition  to  all  choroidal  troubles  is  particularly  marked.  Out 
of  fifty-five  cases,  forty  were  above  thirty  years,  and  of  these  forty,  fourteen 
were  over  fifty  years  of  age.  The  appearance  of  the  disease  usually  coin- 
cides with  the  late  secondary  and  the  early  tertiary  symptoms.^ 

Sufficient  has  been  said  under  iritis  of  the  necessity  for,  and  the  efficacy 
of  the  operations  of  iridectomy  and  paracentesis,  and  of  those  for  the  re- 
moval of  the  eye  when  the  other  is  threatened  by  what  is  known  as  sympa- 
thetic ophthalmia  (a  contingency  which  should  never  be  lost  sight  of),  but 
I  must  refer  the  reader  to  the  various  text-books  on  ophthalmic  surgery 
for  their  minute  description. 

The  complications  which  are  to  be  feared  in  choroiditis  are  extension  of 
the  inflammatory  action  to  the  neighboring  tissues,  to  the  iris  (producing 
irido-choroiditis),  to  the  retina  and  optic  nerve.  There  is  danger  also  of 
exudation  from  the  choroidal  vessels,  producing  subretinal  effusion  with 
subsequent  separation  of  a  part  or  the  whole  of  the  membrane. 

Retinitis. 

The  natural  effect  of  inflammation  upon  this  transparent  membrane 
is  to  give  it  increased  vascularity,  and  cause  effusion  into  its  substance 
and  render  it  opaque.  Hence  one  of  the  earliest  signs  of  retinitis  is  in- 
creased redness  of  the  optic  nerve  entrance,  impai'ting  to  it  a  pinkish 
hue,  or  the  trouble  may  show  itself  simply  by  a  slight  oedema  which  ob- 
scures the  contour  of  the  nerve,  or  the  vessels  which  emerge  from  the 
optic  disk  to  be  distributed  to  the  retina  may  be  abnormally  enlarged,  in- 
jected, and  tortuous,  and  at  certain  points  of  their  course  lost  to  view, 
owing  to  the  opacity  of  the  retinal  tissue  which  covers  them.  Their  rup- 
ture may  also  give  rise  to  small  patches  of  ecchymosis.  Again,  effusion 
into  the  substance  of  the  retina  first  impairs  its  transparency,  and  produces 
the  appearance  of  a  fog  or  haze  in  the  fundus  of  the  eye,  and  finally  en- 
tirely conceals  the  entrance  of  the  optic  nerve,  the  sight  of  which  can  only 
be  determined  by  the  convergence  of  the  dilated  veins.  The  obscurity  of 
the  deeper  structures  may  also  be  increased  by  transudation  into  the  vit- 
reous humor.  Deposits  of  lymph  in  the  retina  may  also  give  rise  to  light- 
colored  patches,  similar  to  those  produced  in  the  choroid  ;  but  the  former 
may  be  recognized  from  the  fact  that  they  conceal  the  choroidal  and  retinal 
vessels,  which  in  the  latter  may  be  seen  to  cross  the  patch. 

Although  the  ophthalmoscopic  appearances  of  specific  retinitis  do  not 
differ  as  a  whole  from  the  non-specific  form,  still,  there  are  certain  pecu- 
liarities attending  it  which  are  supposed  to  be  characteristic  of  its  syphi- 
litic origin. 

'  FoRSTER,  Ilandbuoli  der  gesammten  Augenlieilkuiide,  1876,  vol.  vii,  part  1st, 
p.  191. 


RETINITIS.  723 

Thus,  it  has  been  observed  that  the  inflammatory  changes  do  not,  as  a 
rule,  either  in  the  vascular  system  or  in  the  substance  of  the  retina,  reach 
the  same  intensity  as  in  the  idiopathic  form.  Sometimes,  indeed,  these 
are  so  slight  as  only  to  give  the  idea  of  a  normal  retina  seen  through  a 
delicate  gauze,  which,  however,  has  been  proved  by  the  microscope  to  be 
due,  not  to  any  disturbance  in  the  vitreous,  but  to  changes  in  the  retina 
itself.  The  alteration  in  the  tissue  does  not  as  a  rule  extend  equally  in  all 
directions  from  the  optic  nerve,  but  is  usually  more  developed  on  one  side 
than  the  other,  and  the  border  of  the  disturbance  is  more  sharply  defined 
than  in  the  simple  form,  while  the  exudations  into  the  substance  of  the 
retina  have  a  tendency  to  extend  along  the  vessels.*  Schweigger,^  Von 
Graefe,^  Classen,*  and  others,  have  also  described  some  peculiar  forms  of 
syphilitic  retinitis,  which  with  their  fine-drawn  distinctions,  are,  however, 
of  interest  rather  to  the  ophthalmologist  than  to  the  general  physician,  and 
I  would,  therefore,  refer  the  reader  Avho  is  curious  about  these  matters  to 
the  articles  themselves. 

Retinitis  is  by  no  means  as  frequent  a  symptom  of  secondary  syphilis  as 
iritis;  it  is,  in  fact,  ratlier  a  rare  occurrence,  and  when  it  does  take  place  it 
is  usually  with  the  later  series  of  symptoms :  thus,  in  one  instance  which 
came  under  my  observation,  the  patient  suffered  from  this  disease  fifteen 
months  after  an  attack  of  iritis,  and  at  a  time  when  no  other  syphilitic 
symptoms  were  present.  . 

It  is  certainly  an  interesting  fact  in  this  connection  that  Mooren"  says 
that  he  has  never  seen  specific  retinitis  accompanied  at  the  same  time  by 
any  other  syphilitic  symptoms.  The  same  author  mentions  that  he  has 
often  observed  that  the  subjective  phenomena  of  light  are  more  marked  in 
syphilitic  than  in  the  simple  form  of  retinitis,  and  that  these  are  often 
accompanied  by  zone-like  limitations  in  the  field  of  vision  or  Hemeralopia. 
These  latter  may  also  occur  in  that  form  of  specific  choroiditis  which  is 
attended  with  infiltration  of  pigment  into  the  retina.  When  both  the 
choroid  and  retina  are  affected,  we  have  a  combination  of  the  symptoms  of 
both  under  the  name  of  choroido-retinitis. 

Moreover,  it  must  be  borne  in  mind  that  the  subjective  symptoms  of 
both  retinitis  and  choroiditis  are  often  so  slightly  marked  at  their  com- 
mencement as  to  attract  but  little  attention  from  the  patient,  and  irrepar- 
able mischief  may  be  done  before  their  gravity  is  fully  appreciated.  I 
have  repeatedly  met  with  cases  of  syphilis  in  which  some  slight  complaint 
from  the  patient  has  led  to  an  ophthalmoscopic  examination  of  the  eye, 
disclosing  the  existence  of  a  disease  which  threatened  the  loss  of  sight,  but 
which  was  subsecjuently  arrested  by  appro[)riate  treatment.  Conse(pu'ntIy 
any  impairment  of  vision   in    syphilitic  subjects,  although   unattended  by 

•  For  more  minute  distinctions  see  Lelirbuch  der  Ophtlialmoscopie,  Mautliner, 
Abth.  II,  p.  368.  For  ophthalmoscopic  plates  of  sypliilitic  retinitis  see  Liebreich's 
AtlasT  Tab.  X,  Figs.  1  and  2. 

2  Augenspiegel,  i>ag.  110. 

3  Archiv  fiir  Ophth.,  vii,  2,  p.  211.  *  Archiv  x,  2,  p.  V,7. 
5  Ophthalmologische  Beobaclitungen,  p.  287. 


724  AFFECTIONS    OF    THE    EYES. 

symptoms  of  external  inflammation,  should  at  once  put  the  surgeon  upon 
his  guard,  and  lead  him  to  resort  to  specific  remedies.  Indeed,  the  latter 
are  usually  the  only  resource,  as  operative  interference  is  very  rarely,  if 
ever,  called  for. 

The  prognosis  is  generally  favorable  when  appropriate  treatment  is  em- 
ployed at  an  early  stage  of  the  disease,  and,  in  this  respect,  syphilitic 
choroiditis  and  retinitis  resemble  sypliilitic  iritis. 

Affections  of  the  Optic  Nerve. 

Inflammation  of  the  optic  nerve  or  neuritis  which  is  not  an  extension 
of  the  process  from  the  i-etina  or  choroid,  is  an  extremely  rare  result  of 
the  syphilitic  infection  ;  so  rare  indeed,  that  it  has  been  doubted  by 
competent  authorities  whether  the  optic  nerve  was  ever  primarily  aflfected. 
Thus  Hughlings  Jackson  says,  "■  optic  neuritis  from  syphilis  is  not  syphi- 
litic optic  neuritis.  The  optic  neuritis  produced  by  a  syphilitic  tumor  is 
just  like  that  produced  by  a  glioma  or  by  any  other  adventitious  product 
in  the  cerebrum  or  cerebellum."' 

Forster,  on  the  other  hand,  is  of  the  opinion  that  choked  disk,  dependent 
on  syphilis,  may  occur,  not  as  a  symptom  of  an  intercranial  trouble,  but  as 
the  result  of  gummy  infiltration  of  tissue  between  the  sheaths  of  the  nerve 
rather  than  of  the  nerve  stem  itself.  He  also  calls  attention  to  the  fact 
tliat  by  far  the  greater  quantity  of  cases  of  neuritis  with  syphilis  are  un- 
accompanied by  any  brain  symptom  whatever,  and  moreover  that  it  is  only 
when  the  trouble  is  due  to  syphilis  that  the  most  pronounced  cases  of 
choked  disk  run  their  course  within  a  few  weeks  with  rapid  return  to  the 
normal  condition  under  the  employment  of  specific  remedies.  There  have 
been,  moreover,  a  few  cases  reported  of  gummy  infiltration  of  the  optic 
nerve  itself  by  Graefe,  Hulke,  and  Barber.* 

Westphal  has  also  reported,  as  an  example  of  gummy  infiltration  of  an 
individual  cranial  nerve,  a  case  in  which  the  oculoraotorius  had  been 
changed  into  a  gummy  mass.' 

I  think  therefore  there  is  no  doubt  that  the  optic  nerve  may  be  affected 
primarily  by  the  syphilitic  taint,  which  may  produce  the  symptoms  of 
both  kinds  of  neuritis;  that  is,  the  simple  form  already  described  in  con- 
nection with  retinitis,  and  the  form  known  as  choked  disk,  in  which  the 
predominant  features  are  venous  stasis  with  enlarged  and  tortuous  vessels, 
protrusion  of  the  pai)illa,  uxlema,  and  hemorrhage.  That  these  affections, 
especially  the  latter,  are  more  commonly  the  result  of  an  intercranial 
trouble,  such  as  diflTused  meningitis,  or  concrete  masses  (gummata),  is  of 
course  incontestable ;  but  that  they  may  be  purely  intraocular  I  have  from 
my  own  experience  no  reason  to  dou!)t. 

There  is  nothing  distinctive  between  the  ophthalmoscopic  appearances 
of  syphilitic  and  non-syphilitic  neuritis.  The  origin,  progress,  and  retro- 
gression are  also  the  same,  with  the  exception  that  the  course  of  the  dis- 

■  Ophthalmic  Hospital  Reports,  vol.  viii,  p.  II,  p.  322, 

a  Inaug.  Diss.,  Zuricli,  1873.  »  Jahresbericht  Oplithal.  1873,  p.  436. 


PARALYSIS    OF    THE    EYE.  725 

ease  is  shorter,  and  the  prognosis  is,  as  a  rule,  more  favorable  in  the  spe- 
cific than  in  the  non-specific  form. 

It  should  be  constantly  kept  in  mind  that  the  amount  of  sight  and  the 
field  of  vision  may  be,  and  often  is,  perfectly  normal  in  the  most  pro- 
nounced cases  of  choked  disk,  and  that  for  this  reason  the  practitioner 
must  be  doubly  on  his  guard  so  as  to  detect  the  trouble  at  the  outset.  Any 
complaint  ^vhatever  in  regard  to  the  eye,  should  at  once  demand  a  careful 
examination  into  all  its  parts  and  functions. 

Affections  of  the  Vitreous. 

It  has  already  been  pointed  out  in  the  section  on  choroiditis  that  turbidity 
of  the  vitreous  is  a  common  accompaniment  of  inflammation  of  the  cho- 
roid, but  whether  the  vitreous  is  ever,  under  any  circumstances,  the  seat 
of  a  primary  inflammation  is  still  a  matter  of  discussion  among  ophthal- 
mologists, and  one  which  is  hardly  suitable  to  the  character  of  the  present 
work.  I  will  say,  however,  that  I  have  occasionally  noticed  in  young 
adults  and  those  in  middle  life  who  have  had  syphilis,  a  tendency  towards 
troubles  in  the  vitreous  apparently  unconnected,  so  far  as  the  ophthalmo- 
scope showed,  with  any  trouble  in  the  uveal  tract.  That  such  existed,  but 
of  too  low  a  grade  to  be  detected,  is  of  course  possible,  and  the  disease  in 
these  cases  would  then  be,  as  it  is  in  the  vast  majority,  a  secondary,  and 
not  a  primary,  affection. 

Paralysis  op  the  Nerves  of  the  Eye. 

A  large  proportion  of  the  cases  of  paralysis  of  these  nerves  is  due  to 
syphilis.  Graefe'  attributes  fifty  in  a  hundred  of  all  the  cases  met  with  to 
this  cause,  while  others  have  placed  it  as  high  as  sixty  or  sixty-five  per  cent. 
And  it  is  this  predominating  frequency,  and  especially  the  marked  and  very 
curious  predilection  which  the  virus  would  appear  to  have  in  regard  to  cer- 
tain particular  nerves  of  the  ocular  group,  which  must  be  looked  upon  as 
the  essential  character  of  the  disease.  Thus  in  most  instances  it  is  the 
third  pair,  or  motor  oculi,  that  is  affected;  next  in  order  comes  the  sixth 
pair,"  or  abducens,  and  filially  the  fourth  pair  or  patheticus. 

My  limited  space  compels  me  to  refer  the  reader  to  special  treatises  upon 
diseases  of  the  eye  for  a  detailed  description  of  the  symptoms,  and  for  the 
methods  employed  by  ophthalmologists  in  the  diagnosis  of  these  affections.' 
These  are  much  too  technical  and  intricate  for  the  present  work ;  still  the 
general  practitioner  should  be  aware  of  the  most  prominent  symptoms,  as 
disturbances  in  vision  due  to  a  want  of  co-ordination  of  tlie  eyes  are  often 
the  initial,  if  not  the  sole,  symptoms  of  commencing  cerebral  syphilis — a 
Avarning  which,  if  neglected,  often  leads  to  a  disastrous  result,  but  which, 

»  Syphilitic  Affections  of  tho  Eye,  Deutsch  Klinik,  1858,  No.  21. 

2  Dr.  Beyrarn  has  rehitod  throe  interesting  cases  of  paralysis  of  the  sixth  jiair 
due  to  syphilis,  L'Uniou  Modicalo,  Fel).  23,  1860. 

'  See  an  able  article  by  Dr.  Wells,  givin;^  an  account  of  (iraefe's  rosearclies  upon 
paralytic  affections  of  the  eye,  Ophthalmic  Hospital  Reports,  vol.  ii,  p.  44.  Also 
Diseases  of  the  Eye,  same  Author. 


726  AFFECTIONS    OF    THE    EYES. 

if  seized  upon  at  tlie  moment,  allows  the  application  of  remedies  with  the 
most  beneficial  effect. 

The  principal  symptoms  of  all  these  affections  are  loss  of  power  in  a 
muscle  or  muscles,  and  consequent  limitation  in  the  motion  of  the  eye, 
shown  by  double  images  and  strabismus.  Tiie  individual  characteristics 
are  as  follows: — 

3d  pair.  Falling  of  the  lid,  or  ptosis ;  deviation  outwards  of  the  eye, 
with  loss  of  power  upwards,  inwards,  or  downwards.  Dilatation  of  the 
pupil,  with  loss  or  limitation  of  the  accommodation. 

Gth  pair.  Deviation  inwards,  with  loss  of  power  outwards,  and  double 
vision  on  the  temporal  side  of  the  median  line  of  the  affected  eye. 

4th  pair.  Double  vision  when  looking  at  objects  below  the  horizontal 
plane,  and  a  peculiar  inclination  of  the  ground  or  floor,  with  an  opposing 
inclination  of  the  head  of  the  patient  to  counterbalance  the  disturbance. 

The  paralysis  instead  of  being  complete,  may  be  limited  to  single  mus- 
cles, from  which  it  would  appear  that  different  branches  of  the  nerve  only 
were  affected  ;  or,  instead  of  being  an  actual  paralysis,  it  may  be  only  a 
paresis.  This  "  incompleteness"  has  been  looked  upon  by  some  as  char- 
acteristic of  syphilitic  paralysis,  and  it  is  this  condition  which  has  led  to 
the  supposition  that  there  was  a  "  syphilitic  vertigo."  There  is,  however, 
nothing  sui  generis  in  this  vertigo,  which  may  occur  from  any  cause,  as 
it  is  usually  only  the  expression  of  a  want  of  co-ordination  of  the  muscles. 
The  latter  may  be  so  slight  as  not  to  produce  any  deviation  of  the  axes, 
but  be  just  sufficient  to  interrupt  ti'ansiently  the  perfect  co-ordination  of 
the  muscles  and  produce  a  dizzy  sensation,  but  it  may  on  some  occasions 
produce  for  a  moment  actual  double  vision,  especially  when  the  gaze  is 
turned  in  a  particular  direction.  Still,  it  must  be  borne  in  mind  that  this 
want  of  co-ordination  is  not,  as  asserted  by  some,  the  only  cause  of  vertigo 
in  syphilitic  patients,  as  it  may  exist  and  be  exceedingly  annoying,  even 
when  the  ocular  muscles  are  not  affected  in  the  slightest  degree.  It  must 
then  be  referred  to  an  intercranial  cause  not  connected  with  the  organs  of 
vision,  but  probably  due  to  a  morbid  influence  upon  the  semicircular 
canals.  Among  these  limited  {)aralyses,  one  of  the  most  striking  is  that 
of  monocular  mydriasis,  which  may  occur  even  without  any  implication  of 
the  accommodation  of  the  same  eye.  It  has  sometimes  been  looked  upon 
as  a  precursor  of  severe  brain  trouble,  but  that  it  is  often  not  so,  is  proved 
by  a  number  of  sy[)hilitic  cases  in  which  it  has  appeared  and  then  disap- 
peared with  no  intercranial  symptom. 

Besides  these  simple  paralyses  affecting  a  single  nerve  or  some  of  its 
branches,  there  may  be  a  coincident  paralysis  of  the  other  nerves ;  thus 
the  third  and  sixth  pair  or  the  sixth  and  fourth  pair,  and  so  on,  either  in 
one  or  both  eyes  may  be  affected,  or  there  may  be  a  triple  paralysis,  when 
between  the  two  eyes  the  third,  fourth,  and  sixth  are  all  affected.  The 
paralysis  of  the  ocular  nerves  may  be  also  associated  with  that  of  other 
nerves,  notably  the  facial. 

Owing  to  the  great  importance  of  these  ocular  troubles  and  their  symp- 
toms in  regard  to  the  early  diagnosis  of  cerebral  syphilis,  praiseworthy 
attempts  have  been  made  to  put  the  cause  of  their  greater  fre<iuency  in 


PARALYSIS    OF    THE    EYE.  727 

syphilitic  affections  upon  an  anatomical  basis.  The  principal  reasons  for 
which  are  as  follows:  In  the  first  place,  the  ocular  nerves,  before  entering 
the  orbit,  run  for  a  great  distance  along  the  base  of  tlie  brain  in  contact 
with  the  investing  membranes  and  bony  surfaces,  in  a  region  which  is  the 
place  of  selection  of  all  others  for  syphilitic  inflammations  and  their  pro- 
ducts, such  as  neoplasms,  gummata,  and  sclerosis,  by  which  their  delicate 
nerves  may  be  surrounded  and  compressed ;  and  especially  does  this  refer 
to  the  third  pair,  which  is  even  more  apt  to  suffer  tlian  the  rest,  from  its 
relation  to  the  interpeduncular  space,  which  has  been  shown  to  be  the  seat 
of  predilection  of  intercranial  syphilitic  hyperplasia.^  But  besides  these 
changes  which  lie  at  the  base  of  the  brain,  modern  investigation  has  shown, 
by  clinical  observation  and  by  autopsies,  that  what  have  been  called  nerve 
centres  exist  in  the  cortical  substance  of  the  brain,  so  that  localized  lesions 
in  the  gi'ay  matter  may  produce  a  paralysis  of  a  nerve  or  its  bi'anches 
over  which  the  particular  centre  presides.  And  as  disease  of  the  cortex 
is  frequently  the  result  of  syphilis,  the  connection  between  the  lesion  and 
the  paralysis  is  a  very  probable  one.  This  mode  of  origin  would  also 
explain  the  curious  limitation  of  the  paralysis  to  a  single  muscle,  instead 
of  the  entire  group  over  which  the  nerve  presides. 

The  surgeon  should  carefully  avoid  confounding  paralysis  of  the  sixth 
pair  with  converging  strabismus.  The  two  may  readily  be  distinguished 
by  the  fact  that,  in  the  former,  the  patient  is  unable,  under  any  circum- 
stances, to  turn  the  eye  outwards;  while,  in  the  latter,  if  the  straight  eye 
be  covered,  the  squinting  eye  resumes  its  normal  direction. 

The  treatment  of  jiaralytic  strabismus,  resulting  as  it  so  often  does  from 
syphilis,  is  one  of  the  most  difficult  problems  offered  to  the  ophthalmic 
surgeon,  not  only  in  regard  to  the  fact  whether,  after  all  other  remedies 
have  failed,  an  operation  should  be  done,  but  also  as  to  the  choice  of  the 
operation — whether,  in  fact,  advancement  of  the  paralyzed  muscle  with  a 
tenotomy  of  the  antagonist  should  be  done,  or  a  simple  tenotomy  of  the 
opposing  muscle  with  the  use  of  the  suture,  as  proposed  by  Knapp,  to  in- 
crease the  effect?  I  must  again  refer  the  general  reader  to  special  treatises 
on  the  subject,^  merely  remarking  here  that  the  effect  of  a  tenotomy  is 
often  surprising,  and  that  I  have  known  a  paralytic  squint  from  syphilitic 
causes,  which  had  resisted  all  the  therapeutical  means  known  to  modern 
sypiiilographers,  cured  at  once  by  a  sini[)le  tenotomy. 

Dixon^  relates  two  higlily  interesting  cases,  in  which  examination  after 
death  revealed  the  existence  of  tumors  in  the  substance  of  the  nerve.  The 
paralysis  is  sometimes,  though  rarely,  due  to  disease  of  the  bony  passages, 
or  their  lining  membrane,  traversed  by  the  nerve,  and  has  also  been  traced 
upon  post-mortem  examination  to  softening  of  the  nervous  or  cerebral 
tissue.  Virchow*  quotes  a  number  of  cases  dependent  u[)on  tlie  last-men- 
tioned cause. 

•"  La  syphilis  dii  cerveau,  p.  372  «t  passim,  1ST9.     Par  A.  ForRxiEn. 

2  Among  others,  see  a  paper  entitled,  "  Tlie  Modern  OjH'ration  for  ytrabismus," 
E.  G.  LoRiNG,  Transactions  of  the  New  York  Academy  of  Medicine,  1874,  ji.  lUl. 

3  Medical  T.  and  Gaz.,  bond.,  Oct.  23,  1858. 
*  Sypliilis  constitutionelle,  p.  129  et  seq. 


728  affections  of  the  eyes. 

Hereditary  Syphilis  of  the  Eye. 

That  the  effects  of  acquired  syphilis  in  one  generation  may  be  trans- 
mitted to  the  following,  and  there  manifest  themselves  in  symptoms  analo- 
gous to,  though  perhaps  not  exactly  identical  with,  those  of  the  acquired 
form,  there  can  be  little  or  no  doubt.  Tiius  the  skin  of  the  eyelids  may 
be  the  seat  of  eruptive  diseases,  and  the  deeper-lying  tissue  the  site  of  in- 
filtrations or  destructive  secondary  ulcerations,  with  or  without  a  coexisting 
adenitis  of  the  pre-auricular  and  submaxillary  glands.  Moreover,  the 
hereditary  syphilitic  taint  may  manifest  itself,  so  far  as  the  eyeball  itself  is 
concerned,  in  every  form  of  inflammatory  action  from  a  muco-purulent  con- 
junctivitis to  keratitis,  iritis,  choroiditis,  and  even  retinitis  and  neuritis,  all 
of  which  have  been  described  already  under  their  appropriate  headings. 
Indeed,  so  general  and  numerous  are  the  varieties  of  ocular  disease  that  the 
poison  produces,  that  it  has  been  claimed  that  wdiere  the  result  was  so  gene- 
ral the  cause  could  not  be  individual  and  specific;  and  it  was  consequently 
argued  that  when  these  various  manifestations  occurred  in  broken-down 
and  debilitated  constitutions,  they  were  due  to  the  depraved  condition  of 
the  general  system,  rather  than  the  result  of  a  })articular  morbific  infection. 
And  it  was  brought  forward  as  a  proof  of  this  that  in  the  vast  number  of 
troubles  of  the  eye  there  were  but  two  that  had  any  claim  to  having  any 
individual  and  characteristic  features — specific  iritis  and  keratitis,  and  that 
even  these  two  forms  of  disease  might  occur,  with  all  their  so-called  dis- 
tinctive features,  in  cases  in  which  there  was  not  a  trace  of  any  hereditary 
taint  whatever.  The  weight  of  evidence  is,  however,  against  such  a  rea- 
soning, and  in  favor  of  a  definite  and  distinctive  cause. 

In  the  first  place,  these  troubles  occur  in  the  hereditary  varieties  at  a 
very  early  age,  which  in  the  non-hereditary  forms  only  do  so  at  a  very 
much  later  period.  And  especially  true  is  this  with  infantile  iritis  and 
other  troubles  of  the  uveal  tract;  and  it  may  be  laid  down  as  a  rule,  that 
the  earlier  a  disease  common  to  adult  life  makes  its  appeaiance,  the  more 
likely  it  is  to  be  hereditary.  Moreover,  in  fjivor  of  its  hereditary  nature 
is  the  frequency  in  which  pre-existing  disease  of  a  syphilitic  nature  is 
shown  to  have  occurred  in  one  or  both  of  the  parents,  as  indeed  is  also 
the  fact  of  coexisting  manifestations  in  other  parts  of  the  body  of  the 
parents  or  child — manifestations  which  are  peculiar  to  syphilis  and  not  to 
struma  or  other  diatheses,  such  as  peculiar  eruptions,  erosive  ulcerations, 
nodes,  and  fissures.  To  which  may  be  added  also  the  fact  that  it  is  the 
eldest  child,  or  the  one  born  next  subsequent  to  the  infection  of  the 
parents,  which  is  markedly  predisposed  to  be  affected,  the  frequency  of 
the  attack  and  the  force  of  the  symptoms  decreasing  in  the  later-born 
children,  and,  fin:dly,  the  peculiar  physiognomy. 

Such  evidence  as  this,  and  much  inoi'e  of  a  similar  character,  has  led 
syphilographers,  notably  Mr.  Hutchinson,  to  believe  and  to  declare  that 
tiiese  ocular  troubles,  when  occurring  in  young  persons,  are  almost  always 
the  result  of  an  hereditary  taint  due  to  a  specific  virus — a  conclusion  most 
important  in  a  clinical  point  of  view,  as  upon  it  the  proper  treatment 
depends. 


AFFECTIONS    OF    THE    EXTERNAL    EAR.  729 


CHAPTER    XXV. 
AFFECTIONS    OF    THE    EAR. 

Within  the  last  few  years  much  light  has  been  thrown  upon  this  subject 
by  a  number  of  observers,  among  whom  may  be  mentioned  Gruber,'  of 
Vienna;  Schwartze,"''  of  Halle;  Stohr,^  of  Wurzburg;  and  Roosa,*  Buck,^ 
and  Sexton,®  of  New  York,  and  this  chapter  is,  for  the  most  part,  a  com- 
pilation of  their  labors. 

It  may  be  remarked  at  the  outset,  that  cases  of  syphilitic  disease  of  the 
ear,  or  those  recognized  as  such,  are  rare.  Thus  Buck  has  met  with  only 
30,  out  of  a  total  of  3976  cases  of  ear  affections,  or  a  little  over  three- 
quarters  of  one  per  cent.,  but,  as  stated  by  him,  the  actual  percentage  is 
probably  much  larger,  owing  to  the  difficulty  of  recognizing  the  syphilitic 
element  and  the  tendency  of  patients  to  conceal  the  fact  that  they  have 
had  this  disease.  There  are,  indeed,  in  most  cases,  no  absolute  diagnostic 
symptoms  which  enable  us  to  distinguish  an  affection  of  the  ear  dependent 
upon  syphilis  from  one  due  to  a  non-specific  cause. 

ExTEKXAL  Ear The  only  instance,  so  far  as  I  am  aware,  of  the 

occurrence  of  a  chancre  upon  the  external  ear,  is  reported  by  Alb.  Hulot.' 
There  is  no  reason,  however,  except  the  less  frequent  exposure,  why 
chancres  should  not  be  as  frequent  here  as  on  other  portions  of  the  external 
integument.  This  region  is  not  unfrequently  the  seat  of  secondary  mani- 
festations. Syphilitic  papules  are  met  with  in  the  post-auricular  angle 
and  upon  the  lobule  of  the  ear,  while  the  macular  syphilide  is  most  fre- 
quent on  those  portions  sup[)orted  by  cartilage,  as  the  fossa  navicula.ris 
and  the  concha. 

With  patients  in  the  early  secondary  stage,  we  often  find  impacted 
cerumen,  not  directly  due  to  the  action  of  the  syphilitic  virus,  but  conse- 
quent upon  the  well-known  changes  in  the  activity  of  the  glandular  appa- 
ratus of  the  skin,  which  obtains  generally  at  this  period.  This  fact  was 
mentioned  by  Astruc  as  early  as  1740. 

'  Ueber  Syphilis  des  Gehororgans,  Wien.  rued.  Presse,  1870,  1,  3,  G,  10. 

2  Arch.  f.  Ohrenh.,  WiJrzb.,  1870,  130,  134,  135. 

3  Arch.  f.  Olirenh.,  Wurzb.,  Bd.  v,  s.  139. 

•>  Syphilitic  Affections  of  the  Ear,  Am.  .J.  Syph.  and  Derm.,  N.  Y.,  1871,  p.  97. 
Also  Treatise  on  the  Ear,  4th  ed.,  1878,  p.  521. 
*  Am.  J.  Otol.,  N.  Y.,  vol.  i,  p.  25. 

6  The  Sudden  Deafness  of  Syphilis,  Am.  J.  M.  Sci.,  Phila.,  July,  1879. 
1  Ann.  de  derm,  et  syi)h.,  Paris,  t.  x,  1879,  p.  47. 


730  AFFECTIONS    OF    THE    EAR. 

The  most  frequent  sy[)liilitic  inanifestation,  however,  in  the  external 
auditory  canal,  consists  of  broad  condylomata  (mucous  patches),  which  here 
find  a  fertile  soil  for  development  on  account  of  the  rich  supply  of  glands 
and  papillae  and  the  vascularity  of  the  part.  In  the  external  portion  of 
this  passage,  they  are  usually  isolated,  but  further  inwards  tliey  are  mul- 
tiple and  often  increase  to  such  an  extent  as  to  fill  up  the  canal  vvitli  the 
vegetations  or  papillomata  springing  from  their  surface,  and  they  may  com- 
pletely hide  the  drum.  They  commence  witli  an  ill-defined  swelling  of  the 
deeply  reddened  skin,  followed  by  the  discharge  of  a  sero-purulent  fluid 
which  gradually  uplifts  the  epidermis.  The  appearance  is  now  that  of 
ordinary  otitis  externa,  and  a  mistake  in  the  diagnosis  may  the  more  readily 
be  made  as  the  pain  is  usually  severe.  The  simple  form  of  papule  such  as 
is  met  with  upon  the  body,  is  never  seen  in  the  external  meatus,  nor  is  any 
scaly  eruption,  although  the  latter  is  not  rare  on  the  auricle.  Condylomata 
may  also  be  developed  on  the  drum  and  simulate  acute  or  chronic  inflam- 
mation of  this  membrane,  especially  as  they  may  become  ulcerated  and 
give  rise  to  perforation. 

Again,  in  syphilitic  subjects,  the  auricle  and  the  walls  of  the  external 
meatus  may  be  the  seat  of  ulcerations  usually  rounded  in  form,  which  are 
very  painful  and  obstinate.  In  some  cases  they  appear  to  commence  as 
circumscribed  inflammations,  which  do  not  disappear  after  the  evacuation 
of  the  contained  pus,  as  do  ordinary  abscesses,  but  take  on  the  ulcerative 
process.  Their  surface  becomes  covered  with  a  diphtheritic  secretion  ;  their 
margins  may  extend,  and  the  patient  be  sul)jected  for  a  long  time  to  great 
suffering,  in  spite  of  the  most  energetic  caustic  treatment.  Similar  ulcer- 
ations may  arise  from  gummy  deposits  in  the  cellular  tissue,  the  cartilages, 
or  bones,  more  frequently  in  the  cartilages.  These  deposits  are  for  a  time 
free  from  pain  and  may  be  absorbed  under  anti-sy[)hilitic  treatment,  but, 
in  other  cases,  they  suppurate  and  form  ulcers  of  the  character  described. 

Finally,  among  sy[)hilitic  affections  of  the  external  ear,  we  have  to 
mention  the  aftections  of  the  bones,  as  hyperostosis  and  exostosis.  Gruber 
has  seen  a  number  of  such  cases,  coincident  with  nodes  in  other  regions. 
They  appear  as  circumscribed  swellings  with  rather  more  elevation  than 
is  common  to  nodes  of  this  size.  They  are  often  multiple  and  not  unfre- 
quently  seated  near  the  drum,  so  as  to  cut  off  the  view  of  this  membrane. 
They  may  attain  such  a  size  as  to  interfere  with  the  entrance  of  sound 
waves  and  tluis  impair  the  hearing,  but  such  instances  are  rare.  They 
are  seldom  painful.  Gruber  states  tliat  they  are  sometimes  associated  with 
similar  formations  in  the  bony  portion  of  the  Eustachian  tube,  where  they 
may  cause  marked  narrowing  or  even  complete  stegnosis. 

MiDDLi-:  Eak Of  all  portions  of  tlie  auditory  api)aratus,  tliis   is  the 

most  frequently  aft'ected  by  syphilis,  in  consequence  of  its  intimate  con- 
nection with  the  nose  and  fauces,  where  syphilitic  lesions  are  so  common. 

Mucous  patches  may  form  in  the  Eustachian  tube  or  upon  the  walls  of 
the  middle  ear,  and  eitlier  disappear  under  treatment  or  terminate  in  ulcer- 
ation, destroying  the  tissues  to  a  greater  or  less  extent.     Gruber  states 


MIDDLE    EAR.  731 

that,  when  situated  upon  the  membrane  covering  either  of  the  fenestras  and 
especially  when  situated  upon  the  internal  aspect  of  the  drum,  they  are  liable 
to  excite  very  severe  pain,  which,  unlike  the  pain  of  ordinary  otitis  media, 
does  not  subside  upon  perforation  of  the  membrana  tympani,  but  persists 
until  the  ulceration  is  checked. 

Although  these  statements  with  regard  to  mucous  patches  in  the  Eusta- 
chian tube  and  middle  ear  emanate  from  so  distinguished  an  authority  as 
Gruber,  yet,  when  we  recall  the  inaccessibility  to  observation  of  the  parts 
said  to  be  involved,  their  very  explicitness  cannot  but  cast  a  shadow  of 
doubt  upon  their  value  in  the  mind  of  the  reader. 

It  is  stated  that  syphilitic  disease  of  the  middle  ear  is  still  more  fre- 
quently due  to  the  extension  of  inflammation  and  ulceration  from  the 
nose  and  pharynx.  That  inflammation  may  thus  extend  along  a  continu- 
ous surface,  there  can  be  no  question.  Whether  actual  ulceration  may 
extend  from  the  fauces  to  the  tympanum  is  not  improbable,  but  we  know 
of  no  autopsy  in  which  the  fact  has  been  established.  Gruber  believes  in 
such  extension  of  the  ulceration  and  describes  its  progress  as  follows  :  The 
opening  of  the  Eustachian  tube  is  of  course  first  attacked,  but  the  ulcera- 
tion may  proceed  to  the  destruction  of  the  greater  portion  of  the  organ  of 
hearing.  So  long  as  the  ulceration  is  confined  to  the  Eustachian  tube,  the 
patient  merely  suffers  from  hardness  of  hearing,  abnormal  soimds  in  the 
ear  and  a  sensation  of  tension  or  fulness,  but  as  soon  as  the  middle  ear  is 
invaded  severe  pain  sets  in.  In  these  cases  of  exulceration  of  the  mucous 
membrane  of  the  middle  ear,  changes  may  be  observed  in  the  drum  itself. 
More  or  less  of  its  brilliancy  is  lost  ;  its  surface  becomes  uneven  and  in- 
jected ;  its  whole  substance  may  become  infiltrated  so  that  the  position  of 
the  handle  of  the  malleus  can  only  be  recognized  by  the  injected  vessels 
overlying  it.     Perforation  may  also  occur. 

The  sequela3  of  syphilitic  disease  of  the  middle  ear  are  apparently  the 
same  as  when  the  origin  of  the  trouble  was  not  specific,  but  no  disease  of 
the  middle  ear  of  simple  origin  ever  leaves  the  patient  in  such  a  state  of 
absolute  deafness. 

Among  the  sequela3  are  noted  opacities  or  destruction  of  the  drum  varying 
in  extent ;  loosening  of  the  ossicula  from  their  attachments,  loss  or  impair- 
ment of  the  membranes  covering  the  fenestra?,  and  caries  of  the  temporal 
bone  or  of  the  ossicula.  As  in  ordinary  suppurative  otitis  media,  the  cells 
of  the  mastoid  process  may  be  invaded.  This  may  occur  without  previous 
perforation  of  the  drum  and  hence  without  discharge  from  the  ear,  so  that 
the  afiection  of  the  mastoid  may  erroneously  be  i-egarded  as  primary.  Sup- 
purative inflammation  of  the  middle  ear  caused  by  syi)hilis  is  usually 
chronic,  but  the  Eustachian  tube  may  be  invaded  by  a  sudden  and  severe 
attack  from  the  fauces,  resulting  in  stricture  or  complete  closure. 

Gruber  also  ascribes  certain  cases  of  otitis  media  hypertrophica  to  syphi- 
lis, in  which  are  found  not  only  thickening  of  tiie  lining  membrane,  but 
also  membranous  bands  and  growths  (polypi),  or,  again,  hy[)('r|)lasia  of 
the  bony  tissue  sometimes  affecting  the  ossicles,  either  wholly  and  sym- 
metrically or  partially.     The  hammer  of  the  malleus  is  especially  liable  to 


732  AFFECTIONS    OF    THE    EAR. 

be  thus  jittacked.  Isohited  outgrowths  of  bony  tissue,  varying  in  size,  are 
also  met  witli  on  the  walls  of  the  middle  ear  and  in  the  bony  portion  of 
the  tuba.  The  impairment  of  hearing  wiiich  these  changes  may  produce 
is  evident. 

We  have  omitted  to  mention  one  not  infrequent  cause  of  deafness,  occur- 
ring in  patients  in  the  tertiary  stage  of  syphilis,  who  have  had  gummata 
of  the  soft  palate  with  the  destruction  of  the  soft  parts  that  so  often  follows. 
As  is  w^ell  known,  in  these  cases,  tlie  remains  of  the  soft  palate  often 
become  adherent  to  the  posterior  and  lateral  walls  of  the  pharynx,  where- 
by the  pharyngeal  openings  of  tlie  Eustachian  tubes  are  closed  by  a  me- 
chanical obstruction,  and  greater  or  less  deafness  ensues  which  is  irre- 
mediable. Frequent  instances  of  this  kind  have  come  under  our  obser- 
vation. 

Internal  Ear We  know  nothing  of  syphilitic  affections  of  the  inter- 
nal ear,  although  various  conjectures  have  been  advanced  as  absolute  knowl- 
edge by  some  writers.  It  is  not  unreasonable  to  suppose  that,  when  the 
tympanum  is  the  seat  of  decided  inflammatory  action,  there  may  be  more 
or  less  hypera^mia  or  even  extravasation  of  blood  in  the  internal  ear.  This 
is  asserted  by  Gruber,  who  also  states  that  any  long-continued  interference 
with  the  conveyance  of  sound  may  cause  atrophy  of  the  auditory  nerve, 
"as  shown  by  microscopic  examination  after  death." 

Sudden  Deafness  produced  by  Syphilis. 

Under  this  somewhat  obscure  heading,  it  is  intended  to  include  a  cer- 
tain class  of  cases,  in  which  sudden  deafness  occurs  apparently  as  the  result 
of  syphilis,  but  the  pathology  of  which  is  not  known  Avith  absolute  cer- 
tainty. 

These  cases  may  occur  at  any  period  of  secondary  syphilis,  but  are  most 
common  within  the  first  three  or  four  years.  The  attacks  are  usually  pre- 
ceded by  a  state  of  hypen\3mia  of  the  drums,  either  from  cold  or  from  sym- 
pathy with  the  mouth  or  throat,  thus  inviting,  as  it  were,  an  invasion  of 
the  drum  by  the  specific  affection.  TJiey  are  characterized  by  their  sudden 
occurrence  and  by  the  extreme  amount  of  deafness.  Both  ears  are  usually 
affected  simultaneously,  but  not  always.  The  attack  is  not  attended  with 
pain,  but  there  is  often  a  feeling  of  fulness  in  the  ear,  and  vertigo,  espe- 
cially on  stooping  or  rising  up  suddenly,  and  staggering  of  the  gait  are  not 
uncommon.  Abnormal  sounds  in  the  ear  are  a  troublesome  symptom. 
The  patient  can  hear  his  own  voice  and  also  the  vibrations  of  the  tuning 
fork  placed  upon  the  skull.  Dr.  Sexton  calls  attention  to  a  phenomenon, 
which  he  says  has  not  before  been  mentioned,  viz.,  the  high  pitch  of  all 
sounds  heard  under  certain  conditions.  Thus,  a  player  on  the  cornet  or 
violin,  the  latter  resting  the  base  of  his  instrument  upon  his  neck  beneath 
the  jaw,  will  hear  and  play  his  notes  higher  than  they  are.  He  says 
that  patients  have  told  him  that  the    heavy  concussion  of  a  loaded  truck 


SL'DDEN    DEAFNESS    PRODUCED    BY    SYPHILIS.  733 

passing  over  the  pavement,  or  the  rumbling  of  the  trains  of  the  elevated 
railroad,  produced  a  painfully  high-pitched  sound  like  a  whistle. 

Physical  examination  throws  but  little  light  on  these  cases.  There  is 
commonly  little,  if  any,  affection  of  the  fauces.  The  Eustachian  tube  is 
open  as  shown  by  inflation  of  the  tympanum  by  either  of  the  ordinary 
methods.  There  is  no  evidence  of  any  collection  of  fluid  in  the  middle 
ear.  Dr.  Sexton  punctured  the  drum  in  several  instances  and  found  the 
cavity  empty.  Upon  examination  with  the  aural  speculum,  the  external 
meatus  usually  contains  a  certain  amount  of  a  tenacious  substance  which 
does  not  appear  to  be  either  wax  or  exfoliated  epidermis.  It  is  not  un- 
reasonable to  suppose  that  the  same  exudation  takes  place  in  the  middle 
ear.  The  drum-head  is  somewhat  opaque,  only  slightly,  if  at  all,  injected, 
and  lustreless ;  and  it  is  often  wrinkled  about  the  short  process  of  the  mal- 
leus, in  the  antero-superior  quadrant, — changes  pointing  to  disease  of  its 
internal  layer. 

This  class  of  cases  was  first  clearly  described  by  Sir  "William  Wilde,^ 
under  the  name  of  "  syphilitic  meningitis."  Some  recent  authorities  place 
the  seat  of  this  disease  in  the  labyrinth,  and  Dr.  Roosa  especially,  goes 
still  further,  and  locates  it  in  the  cochlea.  It  is  difficult,  however,  to 
understand,  if  such  be  the  case,  how  patients  are  able  to  hear  their  own 
voices.  Deafness  to  external  sounds  but  the  preservation  of  autophony, 
would  seem  to  point  to  a  defect  in  the  conductive  apparatus  in  the  ear. 
We  are,  therefore,  inclined  to  adopt  the  following  conclusions  of  Dr.  Sexton 
as  an  approximation,  to  say  the  least,  to  the  true  pathology  of  this  affection. 

"1.  Syphilitic  affections  of  the  ears  causing  sudden  deafness,  would 
seem  to  be  induced  by  a  pre-existing  hyperajmia  of  the  ears  excited  by  an 
intercurrent  attack  of  aural  mucous  catarrh. 

"  2.  This  affection  speedily  causes  a  disarrangement  of  the  integrity  of 
the  chain  of  ossicles,  most  likely  at  the  malleo-incudal  joint,  and  probably 
in  some  instances  at  the  incudo-stapedial  joint,  or  both  of  these.  The 
movements  of  the  stapes  in  the  oval  window  are  also  likely  to  be  interfered 
with.  The  two  first-mentioned  conditions  serve  to  explain  the  noises  in 
the  ears  and  the  autophony ;  the  last-mentioned  condition  will  increase 
the  anomalies  of  hearing. 

"  3.  The  affection  does  not  depend  on  anomalies  of  any  portion  of  the 
labyrinth,  although  the  latter,  of  course,  is  liable  to  invasion  from  syphilis, 
with  the  nature  of  which  we  are  as  yet  unfamiliar." 

These  cases  of  sudden  deafness,  in  the  absence  of  pain,  are  commonly 
seen  by  the  surgeon  some  time  after  their  occurrence,  when  they  are 
usually  found  to  be  incurable.  When  seen  early,  very  large  doses  of  the 
iodide  of  potassium  internally  and  the  use  of  mercurial  inunction  give  some 
promise  of  relief  and  perhaps  of  cure,  and  even  at  a  later  period  the  patient 
should  have  the  benefit  of  a  trial  of  these  remedies. 

'  Practical  Observations  on  Aural  Surgery. 


734  affections  of  the  ear. 

Deafness  due  to  Syphilitic  Afi^ections  of  the  Braix. 

Syphilitic  affections  of  the  brain,  occurring  in  such  situations  as  are  in 
direct  or  indirect  relation  with  the  auditory  nerves,  may,  as  would  be  ex- 
pected, give  rise  to  subjective  symptoms  in  the  auditory  ap[)aratus.  The 
negative  result  on  inspection  of  the  ear,  and  the  absence  of  any  symptoms 
referrible  to  the  ear  itself,  will  lead  us  to  ascribe  the  deafness  to  this  cause. 

Schwartze  considers  the  following  symptoms  as  characteristic  of  syphi- 
litic affections  of  the  ear :  the  trouble  is  always  in  both  ears  and  commences 
several  months  after  the  outbreak  of  other  syphilitic  manifestations ;  noc- 
turnal pains  in  the  temporal  bones ;  rapid  impairment  of  hearing,  and, 
finally,  early  impairment  of  the  transmission  of  sound  through  the  bones 
of  the  head. 

Diseases  of  the  Ear  in  the  Subjects  of  Congenital  Syphilis. 

Mr.  Jonathan  Hutchinson,^  in  18G3,  called  attention  to  the  frequent 
occurrence  of  deafness  in  the  subjects  of  inherited  syphilis,  without  any 
adequate  changes  in  the  external  parts  or  in  the  membrana  tympani  to 
account  for  the  same.  Mr.  Hutchinson  states  that  the  age  at  which  deaf- 
ness is  most  liable  to  come  on  appears  to  be  about  the  same  as  that  at 
which  interstitial  keratitis  is  most  frequent,  ^.  e.,  from  five  years  before 
puberty  to  five  years  after  that  period.  In  nearly  all  the  cases  reported  by 
him,  the  loss  of  hearing  affected  both  ears;  in  the  majority  the  patients 
were  utterly  deaf,  and  in  most  of  the  others  the  loss  of  hearing  had  ad- 
vanced to  a  very  considerable  degree.  In  most  of  them  there  had  been 
some  otorrhcca,  but  of  only  a  mild  character. 

Mr.  Hutchinson  adds :  "  It  will  be  seen  that  all  of  the  cases  in  which 
the  ears  were  inspected  go  to  support  the  belief  that  the  deafness  of  syphi- 
litic children  is  due  either  to  disease  of  the  nerve  itself,  or  to  some  changes 
in  non-accessible  parts  of  the  auditory  apparatus.  Its  symmetry  would 
point  to  a  central  cause.  In  none  were  there  found  adequate  changes  in 
the  membrana  tympani,  although  in  none  was  that  membrane  quite  normal. 
In  all  the  Eustachian  tubes  wei'e  pervious,  my  belief  therefore  is,  that  the 
deafness  was  due  either  to  disease  of  the  nerves  or  of  their  distribution  in 
the  labyrinth.  The  cases  constitute  the  analogues  of  syphilitic  retinitis  and 
of  white  atrophy  of  the  optic  nerves.  The  prognosis  is  very  unfavorable. 
From  six  months  to  a  year  would  appear  to  be  the  usual  time  required  for 
the  completion  of  the  process  and  the  entire  abolition  of  the  function." 

Dr.  Dalby,^  Aural  Surgeon  to  St.  George's  Hospital,  states  that,  next 
to  scarlet  fever,  inherited  sypiiilis  may  be  regarded  as  the  most  fruitful 
cause  of  deaf-mutism,  as  it  occurs  in  children  who  are  born  with  good  hear- 
ing [)Ovver.  The  patient  usually  becomes  deaf  in  early  childhood — after 
he  begins  to  talk — or  between  this  period  and  puberty.  With  Mr.  Hutch- 
inson, he  regards  the  disease  as  chiefly  a  nervous  one. 

■  Clinical  Memoir  on  certain  Diseases  of  tlie  Eye  and  Ear,  consequent  on  inherited 
syphilis,  London,  1863,  p.  174. 
^  Lancet,  Loud.,  Jan.  22,  1876. 


HEREDITARY    SYPHILIS.  735 


CHAPTER   XXVI. 

H  E  R  E  DI  T  A  R  Y    SYPHILIS. 

The  %A'orcls  congenital  and  infantile  are  used  to  designate  this  variety 
of  syphilis  ;  the  former  lacks  precision,  and  the  latter  may  be  applied  with 
equal  propriety  to  the  hereditary  and  the  acquired  forms.  The  term 
hereditary  syphilis,  therefore,  seems  preferable.  According  to  Kassowitz,^ 
one-third  of  all  children  procreated  of  syphilitic  parents  are  dead  born, 
and  of  those  born  living  twenty -four  per  cent,  die  within  the' first  six 
months  of  life.  We  may  understand  why  the  lesions  of  hereditary  syphi- 
lis are  so  severe  and  extensive,  and  why  its  fatality  is  so  great,  when  we 
consider  how  early  in  fcjctal  life  the  specific  virus  exerts  its  influence,  and 
how  thoroughly  it  must  be  difl^used  through  the  organism  of  the  embryo. 

In  the  majority  of  cases  of  hereditary  syphilis,  symptoms  appear  about 
the  third  week  of  life.  Some  authors  have  observed  a  postponement  of 
symptoms  until  the  end  of  the  first  year  or  even  later,  but  in  our  experi- 
ence the  twelfth  week  has  been  the  utmost  limit. 

In  case  of  the  infection  of  both  parents,  the  disease  is  likely  to  be  trans- 
mitted in  an  intense  form,  resulting  in  the  death  of  the  foetus  or  in  the 
early  manifestation  of  symptoms. 

There  are  few  exceptions  to  the  rule  that  the  severity  of  the  disease 
decreases  with  each  succeeding  child.  The  danger  of  the  death  of  an 
infected  child  diminishes  as  it  grows  older,  and  freedom  from  symptoms 
until  after  the  sixth  month  justifies  a  favorable  prognosis.  Death  results 
most  frequently  in  cachectic  children,  and  from  gastro-intestinal  aftections, 
which  are  to  a  great  extent  dependent  on  visceral  lesions. 

Syphilis  is  generally  transmitted  only  to  the  second  generation  ;  excep- 
tionally, in  case  of  excessive  activity  of  the  disease  in  the  first  inheritor, 
it  may  appear  even  in  the  third  generation.  The  course  of  hereditary 
syphilis  differs  in  many  res[)ects  from  that  of  the  acquired  disease.  The 
latter  always  begins  by  the  development  of  a  local  lesion,  which  is  followed 
by  a  d(;finite  secondary  period  of  incubation,  at  the  expiration  of  which 
constitutional  manifestations  appear,  while  the  hereditary  disease  presents 
no  initial  lesion  and  cannot  be  divided  into  stages.  Moreover,  while  many 
of  the  lesions  of  each  are  similar,  being  undoubtedly  caused  by  the  syphi- 
litic poison,  on  the  other  hand,  a  large  nunil)er  of  those  in  the  hereditary 
form  are  merely  the  result  of  perverted  nutrition,  and  may  occur  in  any 

'  Die  Vercrbung  (k-r  Sypliilis,  Vienna,  1876. 


736  HEREDITARY    SYPHILIS. 

adynamic  disease.  Among  such  lesions^  nif^y  be  classed  certain  affections 
of  the  eyes,  peculiar  osseous  malformations,  impaired  growth  of  the  hair, 
as  well  as  deafness  and  deaf-mutism,  the  ultimate  cause  of  which  is  un- 
known. 

The  lesions  of  hereditary  syphilis  are  more  hypera^mic  and  active  than 
those  of  the  acquired  form,  and  tend  to  involve  larger  surfaces.  As  a  rule, 
the  early  lesions  are  more  generally  distributed,  and  are  more  symmetrical 
than  those  which  are  developed  later. 

Vesicular  and  bullous  syphilides,  so  rare  in  acquired  syphilis,  are  quite 
common  in  hereditary,  while  rupia  is  almost  unknown  in  the  latter. 
Affections  of  the  nasal  mucous  membrane,  which  are  infrequent  and  ap- 
pear late  in  the  former,  are  among  the  earliest  and  most  reliable  diagnos- 
tic symptoms  of  the  hereditary  disease.  Visceral  affections  are  much 
more  common  in  the  latter  than  in  the  former,  frequently  being  multiple, 
and  coexisting  with  lesions  similar  to  those  of  the  secondary  stage  of  the 
acquired  disease.  Gummatous  and  connective  tissue  infiltrations  are  often 
developed  before  birth,  and  are  more  diffuse  and  symmetrical  when  they 
appear  before  the  end  of  the  first  year  of  life ;  when  seen  after  that  period, 
they  may  present  the  characteristics  of  the  acquired  forms.  A  peculiar 
and  constant  lesion  of  the  ossifying  ends  of  the  long  bones  has  been  ob- 
served during  the  early  months  of  hereditary  syphilis.  Certain  bone 
lesions  may  be  developed  at  a  later  period  which  resemble  those  of  the  ac- 
quired disease.  Affections  of  the  nervous  system,  although  more  common 
than  has  been  supposed,  are  comparatively  rare  in  hereditary  syphilis. 

Evidences  of  hereditary  taint  usually  disappear  before  puberty,  although 
syphilitic  lesions,  undoubtedly  hereditary,  have  been  observed  at  later 
periods,  and  in  some  instances,  after  years  of  apparent  latency.  The 
extent  to  which  inherted  syphilis  furnishes  immunity  to  the  acquired  form 
is  still  undetermined. 

The  opinion,  which  has  been  sustained  chiefly  by  Ricord,  IMaisonneuve, 
and  Montanier,  that  syphilis,  especially  in  its  tertiary  form,  may  be  trans- 
mitted to  offspring  as  scrofula,  phthisis,  or  rickets,  is  utterly  untenable. 

Syi)hilis  is  always  transmitted  as  syphilis,  although  the  cachexia  induced 
by  it  undoubtedly  predisposes  the  infant  to  affections  of  this  kind,  just  as 
any  adynamic  disease  may  do.  The  prevalence  of  this  tendency,  which 
is  quite  rare  in  America,  seems  to  be  very  marked  in  Germany,  where 
Kassowitz  and  Alois  Monte  found  that  nearly  every  syphilitic  child  be- 
came rachitic. 

There  are  not  enough  facts  upon  which  to  base  positive  conclusions  re- 
garding the  possible  production  of  tuberculosis  by  hereditary  syphilis. 
Thoresen,  of  Christiania,  in  a  monograph  on  syphilis  of  the  lungs,  founded 
on  the  study  of  three  hundred  and  eighteen  patients,  states  that  in  every 

'  Dr.  T.  R.  Brown,  of  Baltimore,  Arch,  of  Dermatol.,  N.  Y.,  July,  1877,  reports 
four  cases  of  hare-lip  and  cleft  palate  occurring  in  children  with  hereditary  syph- 
ilis. While  he  does  not  think  that  these  deformities  are  etiologically  related  to 
the  inherited  disease,  he  is  disposed  to  regard  them  as  more  than  coincidences. 


DURATION    AND    PROGRESS    OF    HEREDITARY    SYPHILIS.      737 

case  of  phthisis  in  the  child  there  was  a  history  of"  tuberculosis  in  the 
parents.  It  is  very  probable  that  a  child  who  has  had  a  pulmonary  lesion 
of  hereditary  syphilis  may  be  more  susceptible  to  inflammation  of  the 
lungs  in  after  life. 

Certain  hereditary  tubercular  lesions,  of  late  development,  present 
features  somewhat  similar  to  those  of  lupus,  but  there  is  no  pathological 
relation  between  the  two  diseases,  nor  is  it  proved  that  the  latter  is  of 
frequent  occurrence  during  the  course  of  hereditary  syphilis. 

The  Duration  and  Progress  of  Hereditary  Syphilis. 

The  duration  of  hereditary  syphilis  depends  altogether  upon  two  condi- 
tions: the  intensity  of  the  diathesis  and  the  treatment.  It  is  not  uncom- 
mon for  children  to  present  mild  and  superficial  symptoms  for  a  few 
months  or  a  year,  and  then  become  blooming  and  healthy,  never  again  to 
be  affected  with  syphilitic  lesions.  Again,  severe  and  extensive  lesions 
may  be  exhibited  during  the  early  months,  which  relapse  at  irregular 
intervals  in  an  equally  intense  but  more  limited  form  for  a  few  years;  or 
syphilitic  lesions  may  be  developed  from  time  to  time  until  the  tenth  or 
twelfth  year,  perfect  health  being  established  after  that  time.  In  very 
chronic  cases  symptoms  may  recur  more  or  less  frequently  until  puberty. 
Our  observations  lead  us  to  the  conclusion  that  they  do  not  appear  after 
that  date.  In  general,  the  severity  of  hereditary  syphilis  is  expended 
within  the  first  few  years,  and  subsequent  lesions,  although  possibly  exten- 
sive and  deep,  do  not  show  the  malignancy  of  early  ones. 

The  course  of  hereditary  syphilis  is  equally  clironic  as  that  of  the  ac- 
quired disease,  and  is  even  more  irregular  and  uncertain.  For  this  reason 
the  lesions  cannot  be  arranged  in  chronological  order,  and  a  precise  divi- 
sion of  the  disease  into  stages  is  likewise  impracticable.  Visceral  and 
superficial  lesions  frequently  coexist;  the  interval  between  early  and  late 
lesions  may  be  but  a  few  months  or  even  many  years. 

As  in  the  acquired  form,  so  in  hereditary  syphilis,  the  extensive  super- 
ficial exanthems  are  peculiar  to  the  first  months  of  the  disease.  With 
tliese  may  coexist  lesions  of  the  mucous  membranes,  of  the  bones,  or  of 
the  viscera.  Relapsing  syphilides  are  usually  less  extensive  tlian  the  first 
eruption,  and  their  lesions  are  less  numerous.  They  may  be  composed  of 
either  papules,  pustules,  or  vesicles,  the  eruption  being  polymorphous  or 
made  up  of  one  variety  of  lesion.  The  course  of  these  relapsing  syphilides 
may  be  even  more  chronic  than  that  of  the  first  eruption,  and  the  interval 
between  the  two  may  be  a  few  weeks  or  several  months.  Sometimes  the 
second  rash  appears  before  the  complete  disappearance  of  tiie  first.  It 
may  be  said  that  these  relapses  of  general  eruptions  are,  as  a  rule,  peculiar 
to  the  first  two  or  three  years  of  the  disease.  Subsequent  eruptions  are 
of  another  order,  more  profound,  more  localized,  and  less  likely  to  relapse. 
Thesc'later  orders  of  dermal  lesions  may  be  pnpulo-tubercular,  or  perhaps 
pustular,  but  in  general  they  are  tubercuhir,  tuberculo-ulcerous,  and  gum- 
matous. 
47 


738  HEREDITARY    SYPHILIS. 

These  cases  of  Lite  development  are  rather  rare,  aUhougli  we  liave  seen 
fully  two  dozen  in  which  such  lesions  have  appeared  at  the  third,  sixth, 
eighth,  twelfth,  fifteentli,  and  twentieth  years.  In  fully  one-half  they 
occurred  between  the  fourth  and  twelfth  years,  in  three-eighths  between 
the  third  and  fifth,  and  in  the  remainder  between  the  twelfth  and  twentieth 
years.  It  is  very  rare  to  see  dermal  lesions  extensive  and  superficial  after 
the  second  or  third  year,  they  being  usually  profound  and  limited,  and  in 
this  respect  differing  from  those  of  the  acquired  disease. 

In  the  majority  of  cases  the  development  of  visceral  lesions  takes  place 
in  intra-uterine  life,  and  their  course  after  birth  is  retrogressive.  The 
principal  organs  attacked  are  the  liver,  the  lungs,  the  brain,  and  the 
kidneys.  Our  knowledge  of  the  frequency  and  extent  of  their  development 
after  birth  is  incomplete.  Besides  the  cutaneous  and  visceral  lesions  of 
the  first  year  or  two,  other  syphilitic  affections  ai'e  frequently  observed. 
In  many  cases  the  diaphyso-epiphyseal  lesions  of  tiie  bones  appear  during 
intra-uterine  life  and  run  their  course  in  the  early  months  of  the  disease, 
possibly  relapsing  at  a  later  period ;  or  they  may  appear  for  the  first  time 
during  the  first  year  of  life.  From  the  fourth  up  to  the  twentieth  year 
the  shafts  of  the  bones  may  be  affected  by  periostitis,  and  joint  affections 
often  occur. 

The  lesions  of  the  mucous  membranes  are,  like  those  of  the  skin,  super- 
ficial and  often  extensive  in  the  first  years  of  life ;  at  later  periods  they 
are  circumscribed,  profound,  and  destructive.  Occasionally  iritis,  choroid- 
itis, or  retinitis  occurs,  generally  between  the  third  and  sixth  years,  while 
we  observe  that  keratitis  may  appear  at  any  time  up  to  the  fifteenth  or 
e%en  twentieth  year. 

In  the  somewhat  rare  cases  of  hereditary  syphilis  presenting  cerebral 
and  nervous  symptoms,  it  has  been  noted  that  such  symptoms  and  nutri- 
tional affections  of  the  cranium,  teeth,  etc.,  begin  in  the  early  years  of  life 
and  leave  more  or  less  marked  traces. 

The  severity  of  hereditary  syphilis  exhausts  itself  within  the  fii'st  three 
years  of  life;  whatever  symptoms  are  manifested  after  that  time  are  de- 
veloped in  the  most  chronic  and  irregular  manner.  Therefore,  if  any 
division  of  the  disease  into  stages  were  to  be  made,  the  first  four  years 
might  be  considered  the  first  stage,  or  the  period  of  the  disease  proper, 
the  second  stage  extending  from  that  time  indefinitely,  but  not  beyond 
the  twentieth  year. 

The  Process  of  Procreation. 

The  study  of  hereditary  syphilis  is  much  simplified  by  a  clear  under- 
standing of  the  process  of  ])rocreation,  which  is  described  by  HaeckeP  as 
follows :  "  The  nature  of  fructification  rests  essentially  upon  the  truth  that 
the  male  procreative  cell  becomes   intimately  blended   with   the  female 

1  Anthropologic  Oder  EntwiokelungsgeshichtedesMensclien,  Leipzig,  1875,  p.  138. 
Quoted  by  Kassowitz. 


THE    PROCESS    OF    PROCREATION.  739 

amoeba-like  ovule.  By  tins  means,  in  the  first  place,  the  ovule  is  incited 
to  further  development,  and,  secondly,  the  transmission  to  the  child  of  the 
hereditary  qualities  of  both  parents  is  effected.  The  male  procreative  cell 
entails  upon  the  child  the  individual  character  of  the  father,  and  the 
female  ovum  transmits  hereditarily  to  the  new  being  the  characteristics 
of  the  mother." 

The  embryo  resulting  from  the  union  of  these  two  germinating  cells  is 
nourished  and  matured  in  the  womb  of  the  mother,  through  the  utero- 
placental circulation.  The  influence  of  the  father  upon  the  foetus  is  limited 
to  the  supply  of  organic  cells  at  the  time  of  fecundation ;  that  of  the  mother 
continues  in  a  modified  form  through  the  period  of  gestation.  Since 
numerous  facts  support  the  idea  of  the  transmission  to  offspring  of  mental 
and  physical  qualities,  we  are  warranted  in  assuming  that  diseases,  among 
them  syphilis,  may  be  likewise  inherited,  the  sperm  cells  of  the  male  and 
the  ovule  of  the  female  being  the  conveying  media.  Hereditary  syphilis 
may,  therefore,  be  derived  from  one  or  both  parents,  since  it  originates  in 
the  procreative  cells  of  either  male  or  female. 

Influence  of  the  father So  many  undoubted  instances  of  the  transmis- 
sion of  syphilis  from  father  to  child  have  been  reported,  that  further  evi- 
dence is  scarcely  needed.  The  risk  of  contagion  from  the  father  is  great 
in  proportion  to  the  activity  of  his  symptoms.  If  procreation  takes  place 
while  he  is  in  the  first  period  of  incubation,  the  child  will  escape,  and  may 
do  so  even  during  the  secondary  period  of  incubation,  but  infection  is 
more  probable  as  the  latter  stage  advances.  Probably  his  malign  influence 
begins  with  the  evolution  of  constitutional  manifestations. 

There  is  abundant  evidence  that,  if  the  disease  is  not  treated,  the  sperm- 
cells  will  retain  the  syphilitic  virus  through  the  first  year,  since  temporary 
and  spontaneous  latency  of  the  disease  is  observed  oidy  at  a  later  period. 
On  the  other  hand,  mercurial  treatment  may  so  modify  the  disease,  that 
the  child  will  escape  even  within  the  first  year.  We  see  frequent  exam- 
ples of  this,  when  men  recently  syphilitic  and  compelled  to  marry,  are 
put  under  an  active  mercurial  course,  and  within  a  year  become  fathers  of 
children  who  never  show  the  slightest  evidence  of  syphilis.  Rare  instances 
occur,  in  wliich  the  disease,  although  unmodified  by  treatment,  infects 
the  system  of  the  father  so  slightly,  that  the  foetus  escapes  even  during  the 
first  year. 

Mercurial  treatment,  however,  is  the  most  potent  means  at  our  com- 
mand of  finally  eradicating  the  disease.  Without  it  the  danger  of  trans- 
mitting the  disease  to  offspring  usually  persists  up  to  the  fourth  year  of 
syphilitic  contagion.  By  faithful  pursuance  of  a  mercurial  course  the 
probability  of  the  procreation  of  healthy  cliildren  is  increased  from  year  to 
year. 

Tlic  effect  of  mercury  is  not  always  permanent,  especially  if  it  is  em- 
ployed in  only  a  single  brief  course  during  the  first  year.  Tlie  sperm-cells 
of  the"  father  liaving  as  a  result  of  treatment  ceased  to  procreate  syphilitic 
children,  the  disease  may,  on  the  cessation  of  treatment,  again  become 
active  and  the   next  child  or  children  may  in  consequence  be  syphilitic. 


740  HEREDITARY    SYPHILIS. 

This  fact  has  been  conclusively  proved  by  a  number  of  cases  reported  by 
Kassowitz/  and  also  in  two  cases  under  our  own  observation,^  in  one  of 
■which  tlie  father  was  syphilitic  and  the  mother  healthy.  Seven  chil- 
dren were  born,  of  whom  the  first  five  were  syphilitic,  the  sixth  perfectly 
healthy,  and  the  seventh  markedly  diseased.  In  this  case,  the  mother 
was  healthy,  and  the  disease  of  the  father  was  uninfluenced  by  treatment 
until  after  the  birth  of  the  fifth  child,  when  he  was  under  active  treatment, 
which  was  abandoned  after  the  birth  of  the  sixth. 

Our  chief  points  of  guidance  in  estimating  the  probable  influence  of  a 
syphilitic  father  upon  his  offspring,  are  the  degree  to  which  the  disease 
has  affected  his  system  and  its  amenability  to  treatment.  It  is  well  to  add 
that  the  earlier  a  mercurial  course  is  begun,  the  greater  will  be  its  effect 
upon  the  disease  and  the  more  complete  the  future  immunity  of  the  pa- 
tient. When  the  symptoms  are  trifling,  we  should  not  assume  that  the 
sperm-cells  are  healthy,  on  the  contrary  we  should  insist  upon  an  active 
and  prolonged  course  of  treatment. 

Those  rare  cases,  in  which  distinct  evidences  of  syphilis  are  shown, 
such  as  gummata,  nodes,  palmar  psoriasis,  etc.,  without  any  indication  of 
transmission  of  disease  to  offspring,  have  merely  the  local  relics  of  an 
exhausted  syphilis,  which  give  them  no  immunity  from  fresh  contagion. 

Although  the  paternal  influence  in  transmission  is  now  generally  ac- 
knowledo'ed,  there  are  authorities  who  still  claim  that  the  disease  is  derived 
exclusively  from  the  mother.  This  theory,  now^  known  as  that  of  Culle- 
rier,  who  was  one  of  its  prominent  advocates,  is  based  upon  observations 
which  were  rendered  imperfect  by  failure  to  appreciate  the  facts,  that 
syphilis  may  be  influenced  by  treatment,  and  that  the  disease  has  periods 
of  true  latency. 

In  support  of  this  view,  Cullerier  cites  the  cases  of  two  men,  who,  in 
the  early  stages  of  syphilis  undergo  treatment,  one  even  to  salivation,  and 
of  many  healthy  women  who  bear,  within  a  year  of  man-iage,  perfectly 
healthy  children.  In  the  liglit  of  our  previous  studies,  the  explanation  is 
very  simple.  Moreover,  Cullerier's  articles  show  that  he  has  seen  syphi- 
litic mothers  produce  diseased  children,  and  has  failed  to  learn  the  condi- 
tion of  the  father,  whose  influence  on  the  offspring  is  almost  as  poAvcrful 
as  that  of  the  mother,  and  he  has,  therefore,  reached  a  dangerous  and  false 
conclusion.  It  is  useless  to  consider  in  detail  the  arguments  and  cases  of 
those  who  follow  in  the  same  line,  chief  of  whom  are  Follin,  Notta,  Char- 
rier,  and  Oewre.  We  would  advise  a  perusal  of  the  criticism  upon  this 
theory,  and  upon  the  cases  offered  by  its  advocates,  in  the  admirable  work 
of  Kassowitz. 

We  think  we  are  fully  warranted  in  adopting  the  conclusion  that  the 
father  may  transmit  syphilis  to  his  offsprinfj. 

The  inflxence  of  the  mother In  order  tiiat  syphilis  may  be  conveyed 

by  the  mother,  her  disease  must  be  constitutional.     When  impregnation 

'  Die  Vererlnmg  cler  Syphilis,  Vienna,  1876. 

2  A  contribution  to  the  study  of  the  Transmission  of  Syphilis.  Arch.  Clin.  Surg., 
N.  Y.,  Sept.  1877. 


THE    PROCESS    OF    PROCREATION.  741 

occurs  later  than  within  two  weeks  of  the  evolution  of  general  manifesta- 
tions, the  foetus  is  almost  inevitably  affected,  and  the  activity  of  the  dis- 
ease in  the  child  will  be  in  proportion  to  that  of  its  early  stage  in  the 
mother,  unless  the  disease  has  already  been  modified  by  active  mercurial 
treatment. 

Statistics  show  that  such  embryos  rarely  reach  maturity,  abortion  occur- 
ring usually  from  the  fifth  to  the  seventh  month,  sometimes  as  early  as 
the  third. 

In  such  cases,  in  addition  to  the  disease  of  the  ovule  itself,  the  nutrition 
and  growth  of  the  fcetus,  which  depend  upon  the  richness  and  purity  of 
the  mother's  blood,  are  impaired  in  proportion  to  the  severity  of  the  disease 
in  the  mother,  although  her  specific  syphilitic  influence  ceases  after  con- 
ception. 

The  claim  wdiich  our  own  experience  tends  to  confirm  is  made  by  Four- 
nier  and  others,  that  syphilis  affects  women  more  profoundly  than  men, 
and  that  it  induces  in  them,  more  frequently  and  severely,  a  condition  of 
chloro-ana^mia.  Women  in  this  condition,  becoming  pregnant,  are  doubt- 
less very  likely  to  abort,  while,  on  the  contraiy,  an  embryo,  profoundly 
syphilitic,  may  reach  maturity.  Under  these  circumstances,  treatment 
probably  does  not  cure  the  disease  of  the  fcetus,  but  may  act  upon  it  indi- 
rectly, by  improving  the  condition  of  the  mother. 

In  many  women,  however,  as  in  some  men,  the  course  of  syphilis  is  very 
mild,  and,  during  the  whole  secondary  period,  an  appearance  of  perfect 
health  is  retained. 

The  blood  of  such  women  is,  of  course,  not  profoundly  altered,  hence 
the  nutrition  of  the  child  is  relatively  good.  This  point  will  be  more  fully 
considered. 

Since  arbitrary  rules  regarding  the  parental  influence  in  the  transmission 
of  syphilis  cannot  be  laid  down,  we  shall  give  merely  the  general  results 
reached  in  the  experience  of  reliable  observers,  supplemented  by  our 
own. 

The  frequent  observation  that  the  product  of  conception,  occurring  while 
either  parent  is  in  the  early  and  active  stage  of  the  disease,  is  intensely 
syphilitic  or  fails  to  reach  maturity,  and  that  healthier  children  are  produced 
as  the  disease  of  the  parent  becomes  less  severe,  is  ground  for  the  assertion 
that  the  severity  of  syphilis  in  offspring  is  in  pro[)ortion  to  its  activity  in 
either  or  each  parent,  at  the  time  of  conception.  Thus  if  a  syphilitic  woman 
becomes  pregnant,  or  if  the  disease  is  derived  from  a  man,  in  whom  it  is 
active,  the  first  fcetus  may  live  only  to  the  third  month.  Without  treat- 
ment, the  next  pregnancy  may  have  a  similar  result,  gestation  possibly 
being  a  little  Icjnger. 

As  the  disease  becomes  modified  by  time  or  by  treatment,  a  living,  but 
syphilitic  child,  may  be  born  ;  in  succeeding  pregnancies  the  traces  of  the 
disease  fade,  until,  finally,  healthy  children  may  be  produced. 

This  gradual  extinction  of  tiie  disease  is  to  be  expected  only  when  it  is 
left  to  run  its  own  course.  Modified  by  treatment,  it  may  ofier  many  ir- 
regularities, a  very  striking   instance  being  presented,  where  a  third  or 


7-12  HEREDITARY    SYPHILIS. 

foLirth  child  shows  more  evidences  of  syphilitic  taint  than  its  prede- 
cessors. 

The  power  of  hereditary  transmission  peculiar  to  the  mother  depends, 
as  in  the  case  of  the  father,  upon  the  state  of  the  syphilis  in  her  organism, 
similar  periods  of  latency,  both  spontaneous  and  due  to  mercurials,  being 
met  with  in  the  female.  If  her  system  at  the  time  of  conception  is  tem- 
porarily free  from  syphilitic  influence,  her  ovules  are  capable  of  producing 
healthy  children. 

The  number  of  syphilitic  children  which  a  woman  may  produce  varies. 
In  some  cases,  of  a  mild  character,  healthy  children  may  follow  the  birth 
of  one  or  two  infected  ones.  In  other  cases,  particularly  in  those  partially 
or  entirely  untreated,  there  may  be  six  or  more. 

As  a  rule,  after  the  lapse  of  six  years,  the  influence  of  the  disease  has 
become  so  feeble  that  the  risk  of  transmission  is  extremely  slight. 

Mercurial  treatment  seems  to  have  quite  as  marked  an  effect  in  eradi- 
cating the  disease  and  in  diminishing  its  transmissibility,  with  women  as 
with  men. 

We  have  seen,  in  the  case  of  the  father,  that  the  disease  may  be  tempo- 
rarily so  modified  by  treatment,  that  healthy  children  will  alternate  with 
those  diseased.     The  same  is  true  of  the  mother. 

The  rare  occurrence  of  a  syphilitic  woman  giving  birth  to  twins,  one 
diseased  and  the  other  healthy,  seems  difficult  of  explanation,  but  is  doubt- 
less due  to  the  infection  of  one  ovule  alone. 

Much  light  is  thrown  upon  this  apparent  anomaly,  by  the  fact  that 
certain  syphilitic  cells  or  molecules  may  be  temporarily  confined  to  paren- 
chymatous organs,  while  the  system  at  large  remains  exempt. 

We  come  now  to  an  interesting  question  :  Can  syphilis  he  conveyed 
thi-ougit  the  utero-placental  circulation'^ 

This  mode  of  transmission  is  now  pretty  generally  admitted,  but  many 
discrepancies  are  found  in  the  statements  of  its  advocates. 

It  is  claimed  by  some  that  the  transmission  of  syphilis  to  the  child 
depends  upon  the  occurrence  of  the  mother's  infection  during  the  first  half 
of  pregnancy,  while  others  regard  the  latter  half  as  the  dangerous  period. 
It  seems  singular  that  this  theory  has  been  accepted  at  all,  in  view  of  the 
prevalence  of  so  much  uncertainty  and  lack  of  precision. 

The  question,  however,  is  a  very  simple  one,  namely  :  Can  the  syphi- 
litic virus  of  the  mother  be  conveyed  through  her  blood  to  the  child? 

The  experiments  of  Pellizzari  have  conclusively  proved  that  the  essential 
vehicles  of  the  specific  virus  are  cells  or  albuminoid  molecules  derived  from 
iin  active  syphilitic  lesion.  After  fecundation  the  embryo  is  not  sup- 
plied with  cells  of  any  kind  but  simply  with  serum.  There  is,  therefore, 
after  the  occui-rence  of  conception,  no  possibility  of  the  transmission  of 
syphilis. 

The  literature  of  the  subject  furnishes  not  a  single  reliable  case  in  [)roof 
of  the  tlieory.  Many  cases,  apparently  convincing,  are  reported,  which,  on 
careful  scrutiny,  show  some  vital  defect. 


THE    PROCESS    OF    PROCREATION.  743 

The  following  is  an  illustration  of  this  point :  A  pregnant  woman,  healthy 
at  conception,  becomes  syphilitic  during  gestation,  and  brings  forth  a  pre- 
mature macerated  child,  or  a  syphilitic  child  may  be  born  at  full  term. 
Of  such  cases  certain  authors  say,  that  the  former  was  a  syphilitic  embryo, 
and  that  the  latter  derived  its  syphilis  from  the  mother.  Such  errors  as 
these  are  the  chief  cause  of  the  doubt  now  resting  on  this  question. 

A  syphilitic  woman  may  bring  forth  a  macerated  child,  but,  undeniable 
lesions  of  syphilis  must  be  found  on  the  child  itself  to  prove  its  infection. 

The  antemic  condition  of  the  mother,  and  not  the  specific  poison  in  her 
blood,  may  have  caused  the  pi'emature  expulsion  of  the  child. 

Statistics  show  that  syphilis,  contracted  by  the  mother  during  pi'egnancy, 
is  a  very  prolific  cause  of  premature  birth. 

The  aborted  products,  liowever,  may  differ,  in  no  respect,  from  those 
met  vs'vCa.  in  the  case  of  mothers,  who  have  passed  through  some  severe 
adynamic  disease,  having  no  specific  nature  whatever,  and  cannot  be  called 
syphilitic  in  the  absence  of  undoubted  lesions. 

A  syphilitic  child  may  be  born  at  full  term  of  a  mother  infected  at 
some  time  during  gestation.  It  has  often  been  assumed,  that,  in  such  case, 
the  disease  is  derived  from  the  mother  ;  on  the  contrary,  it  may  be,  and 
always  is  derived  from  the  father.  It  is  possible  for  a  healthy  woman 
carrying  a  syphilitic  foetus,  to  become  infected  herself,  since  the  disease  of 
her  embryo  imparts  to  her  no  immunity.  This  fact  has  been  cited  as  evi- 
dence of  syphilis  acquired  by  the  mother  through  conception,  the  truth 
being,  that  it  was  subsequently  acquired  directly  from  the  fatlier. 

The  importance  of  learning  all  the  facts  relating  to  father,  mother,  and 
child,  before  drawing  conclusions,  seems  to  have  been  often  disregarded. 
As  an  illustration,  we  may  mention  the  recent  article  of  Hutchinson,^  of 
London,  in  which,  of  six  cases  reported,  not  one  bears  out  the  theory  ad- 
vocated, some  lacking  most  important  details,  while  others  are  clearly 
instances  of  syphilis  derived  from  the  father. 

The  cases  cited  by  Oewre,  who  also  supports  this  theory,  are  equally 
unreliable  for  similar  reasons.* 

In  order  to  prove  this  mode  of  transmission  the  following  requirements 
must  be  observed  :  1.  It  must  be  shown  that  the  father  was  free  from  syph- 
ilis at  the  time  of  conception.  2.  The  infection  of  the  mother  during 
pregnancy,  and  her  freedom  from  disease  previously  must  be  proved  be- 
yond doubt.  3.  The  child  must  have  unmistakable  syphilitic  lesions, 
acquired  without  doubt  before  birth. 

We  reach  the  conclusion,  based  upon  the  physiological  reasons  already 

'  A  clinical  lecture  on  the  communication  of  Syphilis  from  a  mother  to  her  foetus. 
Med.  Times  and  Gaz.,  Lond.  Mar.  30,  1877. 

2  Among  those  who  deny  tlie  theory  in  the  most  positive  manner,  and  who  fur- 
nish large  niimhers  of  trustworthy  cases,  may  be  mentioned  Pick,  Ilennig,  Kiibner, 
Spatli,  Schaunstein,  Bidenkap,  Haerensprung,  and  Kassowitz.  IJaerensprung 
details  fourteen  cases,  and  says  emphatically,  that  he  has  never  seen  a  syphilitic 
child  born  of  a  mother  infected  during  pregnancy. 

The  cases  of  Pick  and  Kassowitz  are  also  especially  valuable. 


744  HEREDITARY    SYPHILIS. 

given,  and  upon  the  fact  that  satisfactory  evidence  to  the  contrary  does 
not  exist,  that  the  sypliiUs  of  tJte  motlie?-,  acquired  during  pregnoMcy, 
cannot  he  conveyed  to  the  foetus  through  the  utero-placental  circulation. 

We  now  come  to  the  question,  Can  a  healthy  mother  hear  a  syphilitic 
child'?  It  must  be  evident  that  the  immunity  of  the  mother  depends  upon 
the  same  condition  as  that  of  the  child,  namely,  the  absence  of  cellular 
elements  in  the  fluid  interchanged.  Many  cases  have  been  reported  of 
women  giving  birth  to  syphilitic  children  year  after  year,  while  they  them- 
selves remain  free  from  infection.  AVe^  have  ourselves  reported  two  cases, 
and  have  seen  many  others  of  a  similar  kind. 

Abundant  and  trustworthy  evidence  is  found  in  cases  reported  since 
1801,  when  Swediaur  first  suggested  that  a  syphilitic  foetus  could  not 
infect  the  mother.  Bertin,  Haase,  Colles,  Acton,  Meyer,  Beduar,  De 
Meric,  Trousseau,  and  many  others  have  given  testimony  worthy  of  cre- 
dence. The  most  valuable  is  that  of  Kassowitz,  who,  like  ourselves  has 
followed  cases  from  year  to  year,  and  who  is  an  ardent  advocate  of  this 
view,  never  having  found  any  evidence  in  refutation. 

He  gives  the  carefully  taken  statistics  of  the  Vienna  Foundling  Asylum, 
where,  out  of  four  hundred  children  with  hereditary  syphilis,  one  hun- 
dred and  sixty  had  healthy  mothers,  one  hundred  and  twenty-two  had 
syphilitic  mothers,  and,  in  the  balance  of  the  cases,  the  condition  of  the 
mothers  was  not  known.  In  addition,  he  gives  seventy-six  cases  of  his 
own,  in  forty-three  of  which  the  mothers  were  healthy,  in  twenty-three 
both  parents  were  syphilitic,  and  in  ten  the  mothers  only  were  diseased. 

In  spite  of  this  mass  of  evidence,  there  are  still  those  who  claim  that 
contagion  of  the  mother  by  this  method  is  possible.  Gardien,  in  1826, 
was  the  first  to  do  so,  and  among  its  recent  eminent  advocates  is  Ricord, 
who  called  this  mode  of  infection  "  choc  en  retoury  The  chief  ground 
for  its  acceptance  is  found  in  the  fact  that  mothers,  having  produced 
syphilitic  children,  during,  or  soon  after  pregnancy,  themselves  develop 
specific  symptoms. 

In  such  cases  the  initial  lesion  of  the  father  has  been  overlooked,  or  else 
that  of  the  mother  has  escaped  notice  by  reason  of  its  trifiing  character, 
or  its  inaccessible  location,  as  upon  the  os  uteri. 

Moreover,  in  most  cases,  the  disease  is  fully  developed  in  the  mother 
before  the  birth  of  the  child,  who  may  manifest  no  symptoms  until  several 
weeks  after  birth. 

Even  in  the  absence  of  infecting  lesions  in  the  father,  we  must  bear  in 
mind  that  the  mother  may  derive  her  contagion  from  the  blood  of  the 
father,  arising  from  chafes  produced  during  coitus. 

Moreover,  we  must  consider  the  difficulty  of  gaining  correct  information, 
in  consequence  of  the  reticence  or  forgetfulness  of  the  patients.  Many 
reported  cases  are  based  entirely  on  the  statements  of  patients,  which  can- 
not be  always  trustworthy. 

'  A  Contribution  to  the  Study  of  tli«  Transmission  of  Syphilis.  Arch.  Clin. 
Surg.,  N.  Y.,  Sept.  1876. 


THE    PROCESS    OF    PROCREATION.  745 

Again,  the  active  symptoms  of  disease  in  the  mother  may  appear  so  late 
that  all  traces  of  the  initial  lesion  have  faded. 

To  prove  this  mode  of  contagion,  its  advocates  have  only  one  class  of 
cases  to  offer  in  evidence,  which  we  shall  refer  to  presently. 

That  errors  and  imperfections  are  met  with  in  the  reports  of  these  cases, 
is  strikingly  shown  in  a  recent  article  by  Diday,  in  which  he  gives  twenty- 
six  cases,  most  of  which  are  utterly  valueless,  and  the  others  are  more  or 
less  defective. 

Diday  claims  that  the  syphilis  thus  acquired,  is  similar  to  that  resulting 
from  regular  contagion. 

Hutchinson,  of  London,  twenty  years  ago,  held  that  a  pregnant  woman 
becomes  infected  by  a  syphilitic  fa3tns,  and  that  at  each  succeeding  preg- 
nancy she  receives  fresh  supplies  of  the  poison,  which  thereby  increases  in 
volume  and  intensity,  a  view  which  is  utterly  opposed  by  the  fact  that  in 
each  succeeding  pregnancy  the  children  are  less  and  less  syphilitic. 

Our  only  reason  for  referring  to  it  is  that  the  notion  has  been  recently 
advocated  by  Dr.  Dickinson  of  London. 

From  a  recent  article,  we  learn  that  Hutchinson^  thinks  that  the  infec- 
tion, derived  by  the  mother  from  the  child  is  of  a  modified  variety,  the 
nature  of  which  he  does  not  clearly  understand,  but  which  he  calls  ''blood 
to  blood  syphilis,"  in  distinction  from  what  he  calls  "  chancre  syphilis." 
Still  he  admits  that  he  has  seen  mothers  produce  syphilitic  infants  and 
never  show  any  evidence  of  disease  themselves.  In  this  connection  two 
questions  suggest  themselves  :  Lender  similar  circumstances,  why  are  some 
women  infected  wliile  others  escape  ?  Can  syphilis  exist  without  giving 
any  manifestations  ? 

A  marked  discrepancy  is  thus  seen  to  exist  between  the  views  of  the 
two  chief  authorities  now  living:  Diday,  who  says  that  this  form  of  syi)hi- 
lis  differs  in  no  i-espect  from  the  ordinary  kind,  and  Hutchinson,  who 
claims  that  one  is  a  slight  and  modified  form  of  the  other. 

An  interesting  question,  requiring  further  observation  and  study,  is  with 
regard  to  the  immunity  of  mothers  in  fondling  and  nursing  their  own 
syphilitic  children,  while  nurses  often  contract  chancre  of  the  nipple.  This 
fact  was  first  observed  by  Colles,  and  is  now  called  by  many  "  Colles'  law." 
It  would  seem  to  indicate  that  the  escape  of  the  mother  is  due  to  some 
occult,  undiscernible  change  in  her  system. 

Cases  of  maternal  infection  by  syphilitic  children  have  been  reported  by 
Cazenave,  Brizia  Cocchi,  and  Miiller,  but  they  are  not  conclusive. 

Von  Behrend  and  Deutsch  have  given  cases,  which  tend  to  prove  the 
perfect  health  of  women  who  have  borne  syphilitic  children,  by  the  fact 
that,  on  marrying  a  second,  healthy  husband,  they  produce  children  en- 
tirely free  from  disease. 

For  the  reasons  given,  we  conclude  that,  in  hereditary  syphilis,  the 
disease  is  conveyed  either  by  the  sperm-cells  or  by  the  ovule,  diseased  at 

'  On  Colles'  Law,  and  on  tho  communication  of  Syphilis  from  tho  fcrtus  to  its 
mother.     Med.  Times  and  Gaz.,  Lond.  Dec.  9,  187(5. 


746  HEREDITARY    SYPHILIS. 

the  time  of  conception,  and   that  infection  of  the  mother  or  of  the  child 
cannot  take  phxce  through  the  utero-placental  circuhition. 

Infection  of  the  Child  at  Birth. 

The  view,  now  accepted  by  few,  has  been  uphehl  by  some  authors  that 
the  child  often  becomes  syphilitic  at  birth  from  some  lesion  on  the  genital 
tract  of  the  mother.  In  order  to  establish  this  idea,  it  must  be  proved 
that  the  product  of  conception  was  healthy,  that  the  mother  became  syphi- 
litic during  pregnancy,  and  at  full  term  had  a  contagious  lesion  on  her 
genitals,  and,  moreover,  on  the  child's  body  must  be  developed  a  primary 
lesion,  and  eventually  secondary  symptoms. 

Infection  hy  the  Semen  of  Syphilitic  Men. 

Some  authors  hold  that  infection  of  the  foetus  by  the  semen  can  occur 
only  at  the  time  of  conception,  while  others  maintain  that  it  may  take 
place  at  any  time.  The  cases  which  seem  to  indicate  this  mode  of  con- 
tagion are  those  in  which  the  initial  lesion  has  escaped  observation.  It 
has  been  proved  that  the  semen  is  not  an  infecting  fluid,  as  are  syphilitic 
blood  and  the  secretion  of  specific  lesions ;  moreover,  every  physician  of 
experience  has  met  with  many  instances  of  syphilitic  men  cohabiting  for 
years  with  healthy  women,  who  never  show  any  evidence  of  syphilis. 
We,  therefore,  cannot  admit  the  infectious  properties  of  the  semen  as 
regards  the  female,  or  the  foetus  subsequent  to  conception. 

Invasion  and  Evolution  of  Hereditary  Syphilis. 

Before  considering  in  detail  the  lesions  of  syphilis,  its  evolution  and 
mode  of  invasion  should  be  described. 

The  mortality  of  sypliilitic  children  is  very  great,  fully  one-third  dying 
before  maturity.  Abortion,  resulting  from  the  death  of  the  foetus,  usually 
occurs  about  the  sixth  month,  while  that  caused  by  infection  of  the  mother 
during  pregnancy  takes  place  somewhat  later.  An  aborted  foetus  is  usually 
in  a  macerated  condition,  the  skin  being  easily  detached,  and  the  surface 
having  a  livid  purple  color,  and  various  lesions  will  be  found  in  some  of 
the  viscera.  The  integument  may  show  notliing  characteristic,  or  large 
bullae  may  be  found  on  the  soles  and  palms. 

In  syphilitic  children  stillborn  at  term  or  dying  soon  after  birth,  fre- 
quently no  lesion  of  tlie  skin  is  found.  The  greater  number  of  syphilitic 
children  born  living  appear  well  nourished  and  perfectly  healthy,  but, 
generally  at  the  end  of  three  weeks,  evidences  of  disease  show  themselves. 
The  date  of  the  evolution  of  syphilis  has  been  noted  by  Kassowitz  in  one 
hundred  and  tAventy-four  cases,  in  eleven  of  which  it  was  the  first  week; 
in  twenty-one,  the  second ;  in  thirty-four,  the  third  or  fourth ;  in  forty,  it 
was  the  second  month  ;  and  in  eighteen,  the  third  month.  The  time  seems 
to  depend  upon  the  varying  intensity  of  foetal  infection,  the  early  appear- 
ance of  symptoms  indicating  a  virulent  type  of  disease. 


ERUPTIONS    OF    HEREDITARY    SYPHILIS.  747 

The  prognosis  in  the  case  of  syphilitic  children  is  always  unfavorable, 
death  from  marasmus  often  ensuing  within  a  month,  but  it  becomes  less 
serious  the  later  the  appearance  of  active  symptoms. 

The  first  indication  of  disease  in  a  child,  apparently  healthy  at  birth,  is 
the  characteristic  snuffling,  which  is  the  cause  of  great  discomfort,  and, 
in  some  cases,  death  ensues  from  the  obstruction  to  breathing.  Emacia- 
tion may  progress  to  such  an  extent  as  to  leave  the  skin  of  the  body  loose 
and  wrinkled.  The  integument  of  the  face  seems  to  be  drawn  tight  over 
the  bones,  and  assumes  an  earthy  sallowness.  The  eyes  become  promi- 
nent, and  the  juvenile  expression  is  lost,  until  these  children  come  to  look 
like  little  old  men  and  women.  In  some  cases,  however,  even  of  children 
intensely  diseased,  excessive  emaciation  is  not  observed,  so  that  there 
seems  to  be  no  special  relation  between  this  condition  and  the  activity  of 
the  disease.  Simultaneous  with  these  changes,  the  child's  nutrition 
suffers,  gastro-intestinal  and  pulmonary  lesions  may  be  developed,  and 
various  skin  eruptions  make  their  appearance. 

Eruptions  of  Hereditary  Syphilis. 

The  principal  eruptions  are:  the  erythematous  syphilide,  or  roseola; 
the  papular  syphilide;  the  vesicular,  the  pustular,  the  bullous,  and  the 
tubercular  syphilides;  and  a  form  of  furuncle. 

With  certain  modifications,  the  features  of  syphilitic  eruptions  in  infants 
are  similar  to  those  in  adults.  In  both  cases  they  appear  in  crops,  but,  in 
the  hereditary  disease,  the  later  rashes  are  less  symmetrical  and  are  likely 
to  be  limited  to  particular  regions,  and  the  fever  accompanying  an  erup- 
tion in  the  acquired  disease  is  frequently  absent.  Although  their  general 
course  is  subacute,  yet,  on  account  of  the  activity  of  cell-growth  and  cir- 
culation in  the  integument  of  infants,  the  eruptions  are  developed  rapidly, 
and  tend  to  involve  extensive  surfaces.  It  may  also  be  noticed  that  such 
lesions  as  papules  and  condylomata  are  less  firm  and  solid  than  similar 
ones  in  adults. 

The  Erythematous  Syphilide,  or  Roseola. 

Tliis  is  the  most  frequent  and  the  earliest  hereditary  eruption,  appearing 
about  the  third  week,  and  often  preceded  or  accompanied  by  coryza.  It 
begins  on  the  lower  part  of  the  abdomen  as  minute  round  or  oval  pink 
spots,  which  at  first  disappear  on  pressure.  It  rapidly  invades  the  trunk, 
face,  and  extremities,  and  is  generally  fully  developed  witliin  a  week.  Tlie 
sjjots  then  vary  from  a  third  to  a  half  inch  in  diameter,  assume  a  dull  red 
coppery  hue,  and  no  longer  disappear  on  pressure,  owing  to  pigmentation 
of  the  skin.  In  some  cases,  as  in  adults,  puncta?  of  a  deeper  color  are 
seen  on  the  surface  of  the  roseolous  patches,  denoting  the  situation  of  fol- 
licles, around  wiiich  the  hypenemia  is  more  intense. 

The  patches  are  not  usually  elevated,  and  desquamation  is  generally 
absent,  except  in  severe  cases  about  the  hands,  feet,  and  nates,  where  it 
may  be  limited  to  the  margins  of  the  patches,  or  it  may  be  so  extensive 


748  HEREDITARY    SYTHILIS. 

as  to  resemble  psoriasis.  Sometimes  the  spots  run  togetlier,  and  fissures 
form,  either  superficial  or  of  sufficient  depth  to  cause  much  pain. 

The  early  change  of  color  to  a  coppery  hue,  seen  in  irregular  patches 
upon  the  chin,  in  the  folds  of  the  neck,  and  on  the  nates,  where  other 
lesions  frequently  coexist,  is  an  important  diagnostic  feature. 

The  tendency  to  a  circular  form,  so  common  in  acquired  syphilis,  is 
observed  in  later  hereditary  eruptions  more  frequently  than  in  roseola. 

The  eruption  is  sometimes  so  evanescent,  and  its  color  so  faint,  that  it 
passes  unobserved.  By  attention  to  the  characteristics  mentioned,  and  to 
the  history  of  the  patient,  the  diagnosis  will  generally  be  sufficiently  easy. 

The  Papular  SyphiUde  and  Condylomata  Lata. 

These  lesions  will  be  described  together,  on  account  of  their  pathologi- 
cal similarity. 

The  papular  syphilide  may  be  the  first  eruption,  and  not  infrequently 
it  is  intermingled  with  a  roseola,  or  three  or  four  diffiirent  syphilides  may 
be  seen  at  the  same  time  on  one  child.  The  small  acuminated  papule  of 
acquired  syphilis  is  scarcely  ever  seen,  except  in  a  relapse,  or  late  in  the 
course  of  the  disease.  Flat  papules,  small  and  large,  scattered  symmetri- 
cally over  the  body,  are  the  common  forms.  Crescentic  grouping  is 
seldom  seen  except  at  a  late  period,  and  then  only  about  the  joints  and  on 
the  extremities.  Tlie  papules,  at  first  dull  red,  and  then  coppeiy,  may 
have  a  smooth  surface,  or  the  epidermis  may  exfoliate,  especially  on  the 
soles  and  palms. 

In  this  connection  may  be  mentioned  certain  diffuse  infiltrations,  some- 
times observed,  which  have  not  yet  been  carefully  described.  When  pa- 
pules are  copiously  distributed  upon  the  palms  and  soles,  it  may  be  noted 
that  they  increase  rapidly  in  size  and  number,  and  fuse  together.  The 
skin  is  of  a  dull  red  color,  much  thickened,  and  scaly.  An  entire  foot  or 
hand,  or  the  gluteal  region,  from  the  thighs  to  the  top  of  the  sacrum,  may 
be  thus  involved. 

Irritation  from  active  movements  or  from  pressure,  often  excites  fissures 
and  ulceration,  which  are  the  cause  of  much  suffering.  This  condition 
may  accompany  any  lesion  of  hereditary  syphilis  ;  its  course  is  chronic, 
and  it  is  not,  as  a  rule,  affected  by  internal  medication.  The  duration  of 
the  hereditary  papular  syphilide  depends  upon  treatment,  to  which  it 
promptly  yields. 

Condylomata  lata  are  simply  modifications  of  the  papular  syphilides,  due 
to  their  situation  between  folds  of  skin,  or  at  its  junction  with  mucous 
membranes,  or  wherever  there  is  moisture.  The  change  in  the  papule  is 
chiefly  hypertrophic,  there  being  no  decided  histological  difference  between 
the  two  forms  of  eruption.  In  size  condylomata  vary ;  their  shape  is 
governed  by  the  conformation  of  the  parts  upon  which  they  grow,  and  in 
color  they  are  usually  grayish-pink  to  dark  brown.  Their  surface  is  gener- 
ally flat,  sometimes  fissured  and  ulcerated,  when  a  scanty  offensive  secre- 
tion  exudes,  which  may  form  a  thin   dirty-colored   crust.     Particularly 


ERUPTIONS    OF    HEREDITARY    SYPHILIS.  749 

in  cachectic  infants,  a  false  membrane  may  form,  which  is  slightly  adher- 
ent, and  leaves  a  raw,  bleeding  surface  on  removal. 

When  condylomata  reach  a  diameter  of  more  than  an  inch,  an  unusual 
size,  the  margins  become  elevated  and  rounded,  and  end  abruptly  in  the 
surrounding  skin.  The  latter  may  be  of  its  natural  tint  or  liyperKmic, 
or  it  may  be  the  seat  of  the  diffuse  infiltration  already  spoken  of. 

Condylomata  are  among  the  early  and  most  obstinate  of  hereditary 
lesions,  local  measures  appearing  to  have  more  effect  upon  them  than  in- 
ternal medication.  They  vary  greatly  in  number,  and,  in  infants,  are 
most  frequently  seen  about  the  anus.  A  characteristic  symptom  is  ex- 
hibited when  they  exist  at  each  angle  of  the  mouth,  associated  with  mucous 
patches  in  the  buccal  cavity.  They  are  much  aggravated  by  neglect  and 
want  of  cleanliness,  but  with  proper  care  and  treatment  they  shrink  and 
disappear,  leaving  a  copper-coloi'ed  stain. 

The   Vesicular  Syphilide. 

This  rare  form  of  eruption  occurs  among  the  early  symptoms  in  severe 
cases  of  hereditary  syphilis.  It  is  never  general,  but  is  usually  associated 
with  a  pustular  or  bullous  eruption,  and  appears  in  groups  of  vesicles, 
closely  and  irregularly  packed  together,  upon  the  chin  and  about  the  mouth, 
upon  the  forearms,  the  nates,  the  hypogastrium,  or  the  thighs.  It  rarely 
shows  a  tendency  to  relapse. 

The  size  of  the  individual  vesicles  varies.  The  smallest  are  about  two 
lines  in  diameter,  and  elevated  about  one-quarter  of  a  line  above  the  general 
surface,  are  conical,  contain  transparent  serum,  and  are  situated  upon  a 
firm  infiltrated  base,  which  has  a  brownish-red  color.  Larger  vesicles 
seem  to  be  situated  upon  papules,  and  their  contents  are  sero-purulent. 
Unlike  eczema,  the  distinct  vesicles  show  a  tendency  to  remain  isolated 
and  to  involve  deeper  portions  of  the  skin,  and  rarely  coalesce  to  form 
superficial,  weeping  patches.  Though  chronic  in  its  course,  this  eruption 
generally  yields  to  internal  or  topical  treatment. 

The  Pustular  Syphilide. 

This  eruption  usually  a[)pcars  before  the  eighth  week  in  children  pro- 
foundly sypliilitic,  but  is  not  infrequently  seen  in  those  whose  nutrition  is 
fair.  The  later  it  appears,  the  more  likely  are  the  pustules  to  be  small, 
few,  and  superficial.  It  may  invade  tlie  entire  body,  but  is  usually  more 
abundant  on  the  thighs,  buttocks,  and  face,  while  elsewhere  the  pustules 
are  thinly  scattered  and  irregular. 

The  pustules  vary  from  a  third  of  a  line  to  a  line  in  diameter  at  their 
bases,  and  from  a  third  to  half  of  a  line  in  elevation.  The  deep  red  color 
of  their  thickened  bases  ends  abruptly  at  their  margins.  They  may  remain 
intact  for  many  days,  and,  after  rupture,  the  ulcerated  surface  may  or  may 
not-become  incrusted.  Especially  about  the  mouth,  there  is  a  tendency  to 
grouping  and  the  formation  of  quite  extensive  patches,  or  the  whole  head 
and  face  may  be  thus  involved.    The  crusts  are  generally  darker  than  those 


750  HEREDITARY    SYPHILIS. 

of  eczema  aiid  contagious  impetigo,  and  the  ulceration  beneath  is  deeper. 
Itching  and  burning  are  usually  slight,  but  much  uneasiness  and  even  suf- 
fering may  be  caused  in  certain  locations,  as  when  pustules  form  on  the 
scrotum,  the  buttocks,  or  the  face.  Groups  of  pustules,  attended  by  much 
redness  and  thickening  of  the  surrounding  skin,  may  form  on  the  palms 
and  soles,  and  the  nails  may  be  destroyed  by  pustules  developed  around 
them  or  beneath  their  free  extremities. 

This  eruption  usually  leaves  no  permanent  trace,  but,  in  some  cases 
marked  loss  of  tissue  and  scarring  result,  which  become  less  noticeable  as 
the  child  grows  older.  Sometimes  alopecia  results  from  cicatrices  on  the 
scalp  or  the  alaj  nasi ;  the  free  border  of  the  lips,  or  the  angles  of  the  mouth 
may  be  partially  destroyed. 

The  pustular  eruption  may  or  may  not  be  associated  with  some  other 
form,  the  vesicular  being  seen  with  it  most  frequently.  When  a  second 
pustular  eruption  is  developed  within  the  first  three  or  four  years  of  the 
disease,  it  is  apt  to  be  much  more  limited  in  extent  than  the  first,  but,  in 
other  respects,  is  precisely  similar. 

Fiiriincular  Eraptions. 

As  early  as  the  sixth  month  or  as  late  as  the  third  year,  crops  of  furun- 
cles may  appear,  constituting  the  sole  symptom  of  hereditary  syphilis  or 
associated  with  other  lesions.  If  symmetrically  arranged,  as  they  usually 
are,  they  are  quite  numerous ;  if  irregularly  distributed,  they  are  few. 
They  differ,  in  some  respects,  from  ordinary  furuncles. 

Their  bases  are  usually  compact,  well-defined,  and  of  a  dull  coppery-red 
color.  Their  formation  is  slow  and  without  signs  of  active  inflammation. 
They  begin  as  a  small  nodule  in  the  corium,  and  gradually  increase  to  the 
size  of  half  a  nutmeg.  A  superficial  ulcer  forms  at  the  summit  of  the 
nodule,  and  a  mass  of  slough  comes  away,  leaving  a  deep  cavity,  with 
irregular,  unhealthy  walls  and  everted  discolored  margins,  which  may 
remain  in  a  sluggish  condition  for  many  Aveeks  or  may  increase  in  dimen- 
sions. The  discharge  is  scanty  and  offensive.  Their  duration  is  from  one 
to  several  months,  and  repair  is  often  followed  by  permanent  cicatrices. 

Several  older  writers  have  referred  to  certain  ulcers  about  the  heel  and 
ankles  as  being  diagnostic  of  hereditary  syphilis.  These  ulcers  are  simply 
the  results  of  pustules  or  bullie,  which  are  often  developed  in  those  situa- 
tions and  are  liable  to  irritation,  which  renders  them  very  persistent. 

The  Bullous  Syphilide — Pemphigus. 

This  eruption,  sometimes  seen  at  birth,  and  sometimes  a  month  or  six 
weeks  after  birth,  is  always  indicative  of  a  severe  form  of  hereditary  sy[)hi- 
lis  and  is  frequently  a  precursor  of  death.  As  regards  its  situation,  it 
resembles  the  pustular  syphilide,  but  the  palms  of  the  hands  and  the  soles 
of  the  feet  are  most  frequently  involved,  the  lower  extremities  being  most 
extensively  involved,  while  upon  the  trunk  the  bulhe  are  sparsely  scattered. 

Diffuse  infiltration,  ulceration   and  the  formation  of  fissures  may  attend 


AFFECTIONS    OF    THE    MUCOUS    MEMBRANES.  751 

the  development  of  this  eruption  upon  the  thighs  and  buttocks  and  upon 
the  extremities.  It  may  accompany  pustules,  and,  less  frequently,  one  or 
more  of  the  other  syphilides,  is  generally  copious  and  is  always  symmetrical. 
The  bullie  are  developed  rapidly,  and  their  sero-purulent  contents  soon 
become  purulent.  They  are  surrounded  by  a  rim  of  thickened  integument 
of  a  coppery  color,  and,  unlike  other  forms  of  pemphigus  in  children,  lack 
uniformity  of  shape,  some  being  conical,  others  rounded,  and  still  others 
flattened. 

Although  they  are  developed  rapidly,  the  subsequent  course  of  bullae  is 
chronic.  After  having  been  ruptured  their  progress  is  similar  to  that  ot 
pustules.  It  differs  from  every  other  form  of  eruption  in  being  limited  to 
a  single  outburst,  rarely  or  never  relapsing. 

The  Tubercular  Syphilide. 

This  lesion,  much  rarer  in  hereditary  than  in  acquired  syphilis,  may 
occur  as  early  as  the  sixth  month,  or  a  second  attack  may  be  met  with 
several  years  after  birth.  The  tubercles  begin  as  deeply-seated  papules, 
or  as  small  movable  nodules,  in  the  latter  case  greater  depth  of  tissue 
being  involved.  The  skin  soon  becomes  implicated,  and  a  sharply  defined 
tumor,  from  a  quarter  of  an  inch  to  an  inch  or  more  in  diameter,  results, 
whicli  may  disap[)ear  leaving  no  trace,  or  it  may  break  down  into  an  ulcer 
wliich  is  very  persistent  and  demands  local  as  well  as  constitutional  treat- 
ment. 

Regions  where  the  connective  tissue  is  loose  and  abundant  are  the 
favorite  seat  of  tubercles  of  the  largest  size.  Their  surface  sometimes 
becomes  scaly  and  the  eruption  then  resembles  psoriasis.  Similar  erup- 
tions are  also  seen  in  scrofulous  children,  but  the  greater  surrounding 
hypera^mia,  which  is  of  a  bluish  rather  than  a  coppery  color  in  the  scrofu- 
lous affection,  and  the  points  already  given  in  the  description  of  ulcerations 
of  acquired  syphilis,  may  aid  in  tlie  diagnosis. 

Gummata,  and  Gummatous  Ulcers. 

These  lesions  sometimes  appear  as  early  as  the  third  year  but  generally 
later,  even  as  late  as  the  twentieth  year.  After  this  period,  it  is  not  usual 
for  ulcerations  to  have  the  features  of  hereditary  syphilis,  typical  gummata 
having  been  observed  by  us  in  only  one  instance. 

Tiie  course  of  these  lesions  in  hereditary  syphilis  is  similar  to  that  in 
acquired,  and  therefore  needs  no  additional  description. 

Affections  of  the  Mucous  Membranes. 

One  of  the  earliest  and  most  constant  symptoms  of  hereditary  syphilis  is 
coryza,  which  is  due  to  structural  changes  in  the  mucous  membrane  of 
tho-nasal  passages.  A  few  days  before  the  api)earance  of  general  mani- 
festations there  may  appear  a  serous  discharge  from  the  nostrils,  sometimes 
trifling,  sometimes  so  excessive  as  to  impede  respiration,  especially  during 


752  HEREDITARY    SYPHILIS. 

sleep  and  in  the  act  of  nursing.  This  discharge  is  accompanied  by  the 
characteristic  "  snuffling." 

The  nasal  secretion  soon  becomes  purulent,  bloody  and  very  offensive, 
and  causes  swelling  and  excoriation  of  the  ate  nasi  and  upper  lip.  Tena- 
cious crusts  composed  of  the  dried  secretions  form  on  the  inflamed  sur- 
faces, causing  much  discomfort.  In  its  mildest  and  rarest  form,  this 
affection  is  a  simple  erythema.  Generally,  ulceration  of  the  mucous  mem- 
brane ensues,  and  not  infrequently  the  disease  progresses  to  the  bony 
structures,  producing  necrosis  with  perforation  or  even  entire  destruction 
of  the  septum,  followed  by  striking  deformity. 

The  intensity  and  chronicity  of  specific  coryza,  the  limitation  of  the 
disease  to  the  nasal  passages,  and  the  coexistence  of  other  syphilitic  mani- 
festations are  sufficient  to  establish  the  differential  diagnosis. 

Mucous  Patches  of  the  Mouth. 

In  the  infant  these  lesions  often  lose  their  characteristic  appearance 
quite  early.  At  first  they  consist  of  slightly  elevated  portions  of  mucous 
membrane  with  whitish  surfaces  and  surrounded  by  erythematous  areolae. 
The  pearly  epithelial  covering  may  be  soon  cast  off,  leaving  a  smooth  red 
surface,  slightly  depressed,  which  may  ulcerate.  The  regular  outline  of  the 
round  or  oval  patches  may  be  lost  and  a  number  coalesce,  thus  involving 
a  considerable  extent  of  surface,  which  may  be  superficially  ulcerated  and 
in  cachectic  subjects  is  often  partially  covered  by  an  extremely  adherent 
false  membrane  of  a  pale  brown  color.  The  patches  frequently  become 
hypertrophied  and  resemble  condylomata  lata. 

In  the  early  course  of  hereditary  syphilis  as  many  as  twelve  distinct 
mucous  patches  may  be  counted  ;  at  a  later  period  they  are  less  numerous 
but  they  show  a  decided  tendency  to  relapse,  having  been  seen  by  us  as 
late  as  the  sixth  year. 

The  most  common  situations  of  this  lesion  are  the  angles  of  the  mouth, 
the  mucous  membrane  lining  the  cheeks,  the  piUars  of  the  fauces  and  the 
tonsils,  the  sides,  and  frequently  the  dorsum  of  the  tongue,  and  also  very 
often  the  portions  of  the  gums  adjacent  to  the  teeth.  On  account  of  the 
difficulty  of  pharyngeal  examination  in  young  infants,  we  cannot  state 
positively  the  frequency  of  the  invasion  of  this  region.  There  is  certainly 
less  tendency  to  extensive  ulceration  of  the  pharynx  and  tonsils  in  infants 
than  in  adults.  At  the  angles  of  the  moutli  the  ulceration  is  often  exten- 
sive and  painful. 

The  serous  secretion  of  mucous  patches  is  rather  free,  and  quite  as  in- 
fectious as  that  of  the  initial  lesion.  Hence  the  necessity  of  their  eai'ly 
recognition,  and  of  measures  to  prevent  contagion.  Nursing  at  the  breast 
of  any  one  but  the  mother,  kissing  and  fondling  must  be  prohibited,  and 
great  care  and  cleanliness  must  be  observed  in  the  use  of  bottles,  cups,  etc. 
The  infection  of  the  nurse  by  a  child  having  mucous  patches  of  the  mouth 
is  particularly  liable  to  occur  in  hospitals  and  in  lying-in  asylums.     An 


AFFECTIONS    OF    THE    MUCOUS    MEMBRANES.  753 

instance  of  this  mode  of  contagion  has  been  reported  by  us  in  a  paper/  in 
which  this  question  is  fully  considered. 

Only  when  ulcei'ation  exists,  or  when  the  mucous  patches  are  compli- 
cated with  diphtheritic  membrane,  is  their  diagnosis  from  stomatitis, 
simple  or  parasitic,  attended  by  difficulty.  In  the  absence  of  distinctive 
features  in  the  history  and  on  the  body  of  the  child,  our  decision  must  be 
based  on  the  local  appearances.  In  simple  stomatitis  the  inflammation  is 
generally  more  diffuse,  tlie  whole  tongue,  in  particular,  being  intensely 
affected  and  often  covered  with  vesicles,  which  are  not  seen  in  the  specific 
disease.  The  tendency  of  mucous  patches  to  development  at  the  angles 
of  the  mouth  is  a  valuable  point  in  diagnosis.  In  parasitic  stomatitis  the 
inflammation  is  less  localized  than  in  the  specific ;  the  general  hypera^mia  is 
greater,  and  the  false  membrane  has  a  whiter  color  and  a  more  patchy 
appearance.  In  both  forms  of  non-specific  stomatitis,  the  sulci  between  the 
gums  and  cheeks,  and  the  gums  themselves,  are  often  involved,  rarely  in 
the  specific. 

The  history  of  the  case,  therefore,  and  the  comparatively  circumscribed 
character  and  limited  distribution  of  mucous  patches,  will  enable  us  to 
make  a  diagnosis. 

Gummatous  Injiltrations. 

These  lesions,  consisting  of  cellular  infiltration  of  the  mucous  membrane, 
are  usually  developed  upon  the  hard  palate,  or  upon  the  posterior  pharyn- 
geal wall,  when  they  may  be  mistaken  for  retro-pharyngeal  abscess.  Tiiey 
are  rarely  seen  before  the  third  year  of  life,  and  generally  occur  from  the 
sixth  to  the  twelfth.  The  first  indication  of  their  formation  is  a  reddish 
elevation  of  the  mucous  membrane,  forming  a  round  or  oval  patch,  from 
half  an  inch  to  an  inch  and  a  half  in  diameter,  which  increases  in  size 
and  in  prominence  until  a  well-defined  tumor  results.  Necrotic  changes 
almost  invariably  occur  in  the  tumor,  leaving  an  ulcer  with  sharply  cut,, 
undermined  edges  and  tenacious  greenish  secretion,  involving  the  mucous 
membrane  even  to  the  subjacent  bone. 

Their  course  is  chronic,  with  slight  tendency  to  invade  surrounding 
parts.  Upon  tlie  hard  palate  they  give  little  trouble,  but  upon  the  wall  of 
the  pharynx  they  are  the  source  of  much  suttering  and  inconvenience  in 
swallowing.  The  health  may  be  further  impaired  by  the  copious  secre- 
tions and  the  noxious  gases  developed.  Repair  of  the  ulceration  is  fol- 
lowed by  cicatricial  contractions,  which,  on  the  hard  palate,  may  affect 
phonation,  and,  on  the  wall  of  the  pharynx,  may  interfere  with  deglutition. 
The  diagnosis  is  generally  easy. 

In  strumous  ulceration  of  the  hard  palate,  the  process  is  more  active 
and  less  sharply  limited,  while  other  evidences  of  struma  exist.  Retro- 
pharyngeal abscess  is  much  more  acute  in  its  invasion  and  progress  than 

'  The  Dangers  of  the  Transmission  of  Syphilis  between  Nursing  Chihlren  and 
Nurses  in  Infant  Asylums  and  in  Private  Practice.    Am.  J.  Obst.,  N.  Y.,  Nov.  1875. 
4« 


754  HEREDITARY    SYPHILIS. 

a  gummy  tumor,  and,  in  the  latter  case,  signs  of  pre-existing  syphilitic 
lesions  may  be  found.  In  all  cases  tlie  previous  history  of  the  patient 
must  be  learned. 


Affections  of  the  Larynx. 

In  the  early  periods  of  hereditary  syphilis,  the  larynx  and  upper  air 
passages  may  be  the  seat  of  simple  hyperemia,  of  mucous  patches,  or  of 
ulceration  involving  the  mucous  membrane  or  even  the  cartilages,  to  such 
an  extent  as  to  result  in  stenosis. 

Franke^  reports  the  case  of  an  infant,  in  whose  larynx  there  was  deep 
ulceration  and  perichondritis. 

Coincident  with,  or  following  gummatous  infiltrations  into  the  pharynx, 
similar  lesions  may  attack  the  larynx.  In  six  cases,  as  yet  not  published, 
observed  by  our  friend,  Dr.  Geo.  M.  Lefferts,  destruction  of  this  organ 
in  varying  extent  was  found.  In  three  cases  the  disease  was  limited  to 
the  epiglottis,  which  in  two  was  totally  destroyed,  and  in  one  there  was 
loss  of  half  of  its  free  border.  In  one  of  the  two  cases  of  total  destruc- 
tion, the  ulceration  had  extended  to  the  right  arytenoid  epiglottic  fold. 
In  the  remaining  three  cases,  there  was  general  destruction  of  the  supe- 
rior laryngeal  tissues  with  resulting  stenosis.  i 

In  all  of  these  cases  there  was  greater  or  less  destruction  of  the  pharynx, 
and  the  laryngeal  affection  was  probably  an  extension  of  tlie  morbid  pro- 
cess from  that  region.  Our  knowledge  being  as  yet  so  limited,  we  cannot 
of  course  state  that  the  laxyngeal  affections  are  always  secondary  to  those 
of  the  pharynx,  though  the  histories  of  these  cases  warrant  that  view.  It 
remains  for  future  observation  to  determine  whether,  in  the  course  of 
hereditary  syphilis,  the  larynx  is  primarily  attacked,  with  or  without 
attendant  lesions  of  the  pharynx.  The  ages  of  the  affected  children  varied 
between  ten  and  eighteen  years,  and  the  histories  of  all  of  them  gave  evi- 
dence of  inherited  syphilis. 

Like  gummatous  affections  of  the  pharynx,  those  of  the  larynx  belong 
to  tlie  late  manifestations  of  the  disease.  Like  them,  also,  their  course  is 
quite  rapid,  and  unless  promptly  checked  they  produce  great  deformity. 
Their  symptoms  are  a  varying  degree  of  hoarseness  and  even  total  loss  of 
voice,  with  difficulty  of  respiration  in  the  more  severe  cases.  Iodide  of 
potassium  in  full  doses  should  be  given.  These  affections  are  quite  rare, 
and  their  existence  is  not  even  mentioned  in  most  text-books. 

Affections  of  the  Lungs. 

In  1851,  Depaul  called  the  attention  of  the  profession  to  peculiar  indu- 
rated masses,  found  in  the  lungs  of  infants  affected  with  hereditary  syphilis. 

•  Syph.  Geschwiire  u.  Verengerung  der  Larynx.  Wien.  med.  Wchiisclir.,  no. 
xviii,  1868. 


AFFECTIONS    OF    THE    LUNGS.  755 

He  furnished  specimens  of  this  lesion  to  the  Anatomical  Society  of  Paris, 
who  submitted  them  to  Lebert  for  examination,  whose  report  was  as  follows : 
"  There  is  no  trace  of  pus  in  the  indurated  masses.  The  tissue  presents  a 
peculiar  yellow  color,  and  is  elastic  and  resistant.  In  the  midst  of  a  net- 
work of  normal  pulmonary  tissue  is  found,  mingled  with  fibro-plastic  ele- 
ments, a  soft,  pulpy  and  diffused  substance,  containing  small  cells,  which 
differ  from  those  of  cancer  and  tubercle,  and  which  resemble  in  every 
respect  those  seen  in  syphilitic  gummata.  These  specimens  may  therefore 
be  regarded  as  an  early  stage  of  pulmonary  gummata,  which  first  appear  as 
indurated  masses,  afterwards  assume  a  yellow  and  pulpy  appearance,  and 
finally  soften,  so  as  to  resemble  purulent  infiltration  or  an  abscess."^  In  his 
treatise  on  Patliological  Anatomy,  Lebert  gives  a  plate  of  one  of  these 
masses,  which  he  compares  with  certain  pneumonic  products.^ 

Within  the  past  ten  years,  much  has  been  contributed  by  various  ob- 
servers to  our  knowledge  of  pulmonary  changes.  Interstitial  cell  pro- 
liferation, sometimes  complicated  with  gummatous  infiltration,  seems  to  be 
the  principal  change. 

When  the  lesions  are  extensive  and  fully  developed,  the  lung  is  reduced 
in  size,  increased  in  consistency,  and,  when  cut,  is  found  to  be  firmer  and 
less  vascular  than  normal.  Scattered  upon  the  surface  of  the  lung  and 
through  its  substance,  on  the  smaller  vessels  and  bronciii,  which  are  much 
thickened  and  look  like  yellow  cords,  are  numerous  nodules  of  various 
sizes.  The  more  recent  are  small  and  of  a  grayish-pink  color ;  the  older  ones 
may  be  the  size  of  a  filbert,  are  light  yellow,  and,  when  incised,  exude  a 
thin  milky  fluid,  while  serum  escapes  from  the  lung  substance.  The  former 
appear  to  be  homogeneous,  while  the  latter  are  granular  and  may  contain 
pus.  The  pulmonary  pleura,  especially  in  the  vicinity  of  the  nodules,  is 
tliickened  and  opaque. 

The  entire  lung  is  usually  more  or  less  involved  in  the  morbid  processes, 
though,  in  some  cases,  the  nodules  may  be  few  and  confined  to  a  portion 
of  a  single  lobe. 

The  first  step  in  the  ])rocess  is  evidently  active  congestion,  followed  by 
cell  proliferation  around  the  bronchioles,  and,  in  a  less  degree,  in  tlic  walls 
of  the  capillaries,  resulting  in  partial  or  complete  obstruction  of  tlieir  lumen 
and  consequent  destruction  of  tlie  function  of  the  lung. 

The  nodules,  which  represent  one  or  more  plugged  and  distended  alveoli, 
consist  of  a  mass  of  connective  tissue  cells,  fibrous  tissue,  granular  debris 
and  perhaps  some  gummatous  tissue.  Like  all  new  growths,  they  are  liable 
to  degeneration,  fatty  or  caseous,  and  may  contain  pus  in  tlieir  centres. 
The  pleural  changes  are  due  to  hypertemia  and  increase  of  fibrous  tissue. 
True  gummatous  nodules  have  been  found  by  some  observers.  While  two 
forms  of  nodules,  tlie  gummatous  and  the  connective  tissue,  may  exist,  their 
gross  and  microscoi)ical  appearances  are,  in  some  cases,  so  very  similar, 

>  Bull.  Soc.  anat.  dc  Paris,  1852,  p.  23. 

2  Traite  d'anatoinio  pathol.  I'l.  viii,  figs.  3  and  4. 


756  HEREDITARY    SYPHILIS. 

that  it  is  impossible  to  distinguish  them.  The  gray  hepatization  of  pneu- 
monia resembles  syphilitic  induration,  but  may  be  recognized  by  the  greater 
succulence  and  less  resistance  of  the  lining  tissue  and  by  the  escape  of  true 
pus  on  pi-essure.  Owing  to  the  nature  and  extent  of  these  pulmonary  lesions, 
life  is,  in  most  cases,  destroyed.  They  may,  however,  exist  in  a  moderate 
and  localized  form,  without  such  a  result. 

A  child,  five  months  old,  who  had  passed  tlirough  the  early  period  of  its 
disease,  having  had  a  papular  and  pustular  eruption,  developed  broncho- 
pneumonia, with  dulness  on  percussion,  imperfect  expansion,  and  harsh 
respiratory  sounds,  with  slight  crepitation  at  the  right  apex  and  over  the 
lower  lobe  of  the  left  lung.  Although  there  was  excessive  cough,  the  in- 
crease in  pulse  rate  and  in  temperature  was  very  slight  and  no  acute  symp- 
toms of  any  kind  were  exhibited.  This  condition  lasted  fully  six  weeks, 
and  finally  yielded  to  the  mixed  treatment  in  gradually  increasing  doses. 
We  examined  this  infant  six  months  later,  and  there  were  no  perceptible 
traces  of  the  lesion  in  either  lung.  We  have  seen  two  cases  essentially 
similar  both  in  course  and  in  method  of  cure,  in  which  lesions  of  the  bones, 
joints,  eyes  and  integument  w^ere  also  present. 

While  these  changes  usually  take  place  in  intra-uterine  life,  we  may  find 
them  at  any  time  when  the  syphilitic  diathesis  is  active,  but  most  frequently 
within  the  first  eighteen  months  of  life.  They  are  not  attended  by  much 
systemic  reaction,  and  m.ay  be  developed  in  any  portion  of  the  lung  either 
symmetrically  or  unilaterally. 

Affections  of  the  Peritoneum. 

Primary  morbid  changes  are  rarely,  if  ever,  seen  in  the  peritoneum. 
Thirty-one  cases,  in  which  general  or  partial  uncomplicated  infiammation 
of  this  membrane  was  distinguished,  have  indeed  been  reported  by  Simp- 
son,' who  claims  the  existence  of  true  peritonitis. 

The  syphilitic  origin  of  many  of  these  cases  was,  however,  doubtful,  and 
in  some  the  exact  condition  of  the  viscera  was  not  observed.  Chronic 
adhesive  peritonitis,  more  or  less  localized  and  unattended  by  marked 
symptoms,  often  occurs,  originating  in  some  sypliilitic  visceral  change  par- 
ticularly of  the  liver. 

Affections  of  the  Alimentary  Canal. 

The  mild  chronic  diarrhoeas  observed  in  syphilitic  children,  other  causes 
being  eliminated,  seem  to  indicate  the  presence  in  the  gastro-intestinal 
tract  of  erythematous  affections  similar  to  those  seen  in  the  mouth  and 
pliarynx.      Structural  changes  have  been  found  by  various  observers. 

Forster^  has  described  a  fibroid  degeneration  of  Peyer's  patches  in  a 

«  Edinb.  M.  and  S.  J.  no.  37. 

2  Wurzb.  incd.  Ztsclir.,  Band  iv,  pcart  1,  1863. 


AFFECTIONS    OF    THE    LIVER.  757 

syphilitic  infant  who  died  six  days  after  birth,  with  lobular  pneumonia  and 
purulent  bronchitis.  The  glandular  structure  of  the  patches  had  been 
replaced  by  elevated  grayish-red  masses,  with  smooth  surface  and  yellowish 
centre,  composed  of  nuclei,  cells  and  fibres  of  connective  tissue.  Similar 
observations  have  been  made  by  Eberth,^  Roth,^  and  Oser,^  who  have  de- 
scribed an  affection  consisting  of  multiple  circumscribed  indurations,  vary- 
ing in  size  and  generally  circular,  situated  on  a  level  with  Peyer's  patches 
and  the  solitary  glands,  the  surrounding  mucous  membrane  being  smooth 
and  slate-colored,  or  more  or  less  ulcerated.  The  latter  condition  resembles 
that  of  a  dry  eschar,  but  leaves  an  ulcer  with  a  bright  lardaceous  base. 
This  lesion,  consisting  of  an  infiltration  of  cells  similar  to  those  of  lymph- 
atic glands  and  of  connective  tissue,  is  usually  limited  to  the  submucous 
stratum. 

Affections  of  the  Liver. 

The  functional  activity  of  the  liver  in  infancy  renders  it  subject  to  pro- 
found structural  changes,  which  consist  chiefly  of  connective  tissue  infil- 
tration. The  credit  of  first  calling  attention  to  this  important  lesion 
belongs  to  Gubler,*  from  whose  writings,  mainly,  Diday  was  enabled  to 
give  the  following  clear  and  complete  description,  of  which  we  avail  our- 
selves : — 

"When  the  lesion  has  reached  its  maximum,  the  liver  is  sensibly  hyper- 
trophied,  globular,  and  hard.  It  is  resistant  to  pressure,  and  even  wlien 
torn  by  the  fingers  its  surface  receives  no  indentation  from  them.  The 
elasticity  of  the  organ  is  such,  that  if  a  wedge-shaped  piece  taken  from  its 
thin  edge  be  pressed,  it  esca[)es  like  a  clierry-stone,  and  rebounds  from  the 
ground.  AVhen  cut  into,  it  creaks  slightly  under  the  scalpel.  The  dis- 
tinct nature  of  its  two  substances  has  completely  vanished.  On  a  uniform 
yellowish  ground,  a  more  or  less  close  layer  of  small,  white,  opacpie  gi-ains 
is  seen,  having  the  appearance  of  grains  of  semola,  with  delicate  arl)ores- 
cences,  formed  of  empty  bloodvessels.  On  pressure  no  blood  is  forced  out, 
but  only  a  slightly  yellow  serum,  which  is  derived  from  the  albumen. 
Gubler  has  only  three  times  seen  the  change  carried  to  this  extent.  It 
is  most  frecpsently  much  less  marked.  Tlius,  the  tissue  of  the  organ  is 
firm,  without  having  that  extreme  hardness  and  yellow  color,  which  might 
admit  of  comparison  to  some  kinds  of  flint.  The  interior  of  the  organ 
presents  rather  an  indefinite  color,  shaded  with  yellow  or  brownish-red, 
more  or  less  diluted;  but  in  no  part  is  the  parenchyma  quite  healthy  in 
appearance. 

'  tJebftr  syi)h.  Enteritis.  Arch.  f.  jj-atli.  Anat.,  etc.,  Berlin,  Band  xl,  page  326, 
18G7.     Quf)t(^d  by  Lancereaux. 

2  Knteritis  syphilitica.     Ibid.,  Band  xliii,  p.  2!)8. 

3  Filllo  von  Ent(!ritis  syphilitica.  Arch.  f.  Dermat.  u.  Syi)h.,  Prag.,  Band  iii, 
1870." 

■*  Memoire  sur  une  nouvelle  affection  du  foie,  Hue  a  la  syphilis  herfiditaire  chez 
les  enfants  du  premier  age.     Gaz.  med.  de  Paris,  1852. 


758  HEREDITARY    SYPHILIS. 

"Again,  the  change  may  be  found  in  circumscribed  parts  only.  Gubler 
has  seen  it  confined  to  the  left  lobe,  to  the  thin  edge  of  the  right  lobe,  and 
to  the  lobulus  Spigelii.  He  ascertained  by  injections  that,  in  tlie  indu- 
rated tissue,  the  vascular  network  is  almost  impermeable;  that  the  capil- 
lary vessels  are  obliterated,  and  that  even  the  calibre  of  the  larger  vessels 
is  considerably  diminished.  Microscopical  examination  enabled  him  to 
discover  the  cause  of  this  disposition  by  revealing  in  the  altered  tissue  of 
the  organ,  in  every  degree  of  change,  the  presence  of  tibro-plastic  matter, 
sometimes  in  considerable,  sometimes  in  enormous,  ([uantity.  In  the  por- 
tions intervening  between  the  diseased  parts,  the  cells  of  the  hepatic  paren- 
chyma maintain  all  the  chai'acteristics  of  their  normal  condition.  The 
physical  consequences  of  the  deposit  of  these  elements  are  an  increase  in 
the  volume  of  the  liver,  the  compression  of  the  cells  of  the  acini,  the 
obliteration  of  the  vessels,  and  the  consequent  cessation  of  the  secretion  of 
bile.  In  all  the  subjects  examined  after  death  by  Gubler,  he  always  found 
the  bile  in  the  gall-bladder  of  a  pale  yellow  color  and  very  sticky;  that  is 
to  say,  very  rich  in  mucus  and  very  poor  in  coloring  matter." 

Later  observations  confirm  the  results  obtained  by  Gubler,  and  add 
much  to  our  knowledge  of  the  microscopic  changes  found  in  the  liver. 
The  primary  changes  are  vascular.  Tiie  walls  of  the  vessels  are  much 
thickened,  and  around  the  tunica  adventitia  numerous  nuclei  and  cells, 
with  an  abundance  of  tine  fibrillar  connective  tissue,  are  found.  The 
calibre  of  some  of  the  vessels  is  diminished,  and  that  of  others  is  entirely 
obliterated.  Moreover,  various  stages  of  fatty  degeneration  of  the  hepatic 
cells  are  found.  Increase  of  connective  tissue  is  observed  in  the  paren- 
chymatous network  of  the  organ  and  in  the  capsule,  which  may  be  thick- 
ened either  in  its  entire  extent  or  especially  on  its  upper  surface.  Adhe- 
sions may  form  between  the  convex  surface  and  the  diaphragm  or  the 
peritoneum  of  the  anterior  abdominal  wall.  Certain  changes  in  the  veins 
have  been  described  by  Scliiippel,  under  the  title  "peripyle  phlebitis  syphi- 
litica," which  will  be  spoken  of  in  the  section  on  aifections  of  the  circula- 
tory organs. 

Gummous  hepatitis  in  hereditary  syphilis  is  admitted  by  several  authors. 
There  are  two  forms,  one  consisting  of  numerous  minute  tumors  scattered 
through  the  liver,  called  by  Wagner  miliary  syphilome;  and  the  other 
consisting  of  one  or  more  large  circumscribed  tumors,  such  as  are  found 
in  the  adult.  Either  of  these  lesions  may  be  accompanied  by  the  fibro- 
plastic infiltration  of  Gubler. 

The  clinical  history  and  microscopic  anatomy  of  this  affection  have  been 
carefully  studied  by  Rochebonne,  a  former  student  of  Prof  Gubler.  This 
observer  thinks  that  a  diagnosis  may  be  made  from  the  following  symp- 
toms :  A  deep  wine-colored  venous  stasis  and  oedema  of  the  lower  ex- 
tremities, often  accompanied  hy  pemphigus;  ascites,  due  to  mechanical 
obstruction  of  the  circulation,  as  in  cirrhosis;  a  more  or  less  pronounced 
chloro-angemic  appearance  of  the  face ;  and  the  presence  in  the  urine  of 
albumen  and  lurmato-globulin.  Vomiting  may  occur,  and  constipation, 
alternating  Avith  diarrhoea,  has  been  observed.     Icterus,  symptomatic  of 


AFFECTIONS    OF    THE    SPLEEN.  759 

this  affection,  has  not  been  noticed.     A  fatal  result  commonly  ensues  in 
tlie  early  weeks  of  the  child's  existence. 

AfFECTIOXS  of  THE  SpLEEN. 

In  cachectic  children  and  in  those  in  whom  the  disease  assumes  a  severe 
form,  more  or  less  hypertrophy  of  the  spleen  is  sometimes  observed,  usu- 
ally during  the  early  stages  of  syphilis.  The  enlargement  is  i*apid,  the 
size  of  the  organ  often  being  quadrupled  in  two  or  three  weeks.  This  con- 
dition may  persist,  according  to  Barlow,  even  for  a  year,  while  on  the 
other  hand,  mercurial  treatment  induces  its  rapid  subsidence. 

Although  we  are  ignorant  of  the  pathology  of  this  affection,  the  acute- 
ness  of  its  invasion  and  its  rapid  involution  suggest  hyperaemia  rather  than 
permanent  cell-growth.  Still  it  is  quite  possible  that  cellular  hyperplasia 
may  take  place  in  tlie  spleen,  as  it  does  in  the  liver.  Lancereaux  says  that 
the  hypertrophied  spleen  is  tirm  and  smooth,  that  it  sometimes  becomes 
adherent  to  other  organs,  that  the  condition  is  often  a  simple  multiplication 
of  cell-elements,  and  that  affections  of  the  liver  and  perhaps  of  tlie  lympha- 
tic glands  generally  coexist. 

Gee,  who  first  described  the  affection  in  18G7,  stated  that  it  occurs  in  at 
least  one-half  the  cases  of  hereditary  syphilis,  and  in  one-fourth  hypertro- 
phy is  excessive  and  accompanied  by  a  similar  condition  of  the  liver  and 
the  lymphatics.  In  two  post-mortem  examinations  he  found  enlargement 
and  induration,  without  evidence  of  gummatous  infiltration  or  of  amyloid 
degeneration. 

In  view  of  its  gradual  diminution  as  the  general  condition  of  the  child 
improves,  splenic  hypertrophy  is  regarded  by  Gee  and  Barlow  as  an  evi- 
dence of  the  severity  of  the  syphilitic  cachexia. 

According  to  Parrot^  there  are  two  forms  of  splenic  lesion  caused  by 
hereditary  syphilis.  The  first  is  an  hypertrophy,  in  Avhich  the  organ  may 
become  three  times  its  natural  size,  which,  he  thijiks,  is  a  secondary  result 
of  portal  obstruction,  caused  by  diff'use  infiltration  of  the  liver,  the  spleen 
then  being  compelled  to  serve  as  a  reservoir  of  the  blood. 

The  second  form  is  an  inflammation  resulting  in  the  formation  of  false 
membranes  around  the  capsule  of  the  organ.  Parrot  is  not  positive  regard- 
ing the  future  course  of  these  lesions,  but  is  inclined  to  attribute  to  them 
certain  lardaceous  degenerations  found  later  in  the  life  of  children,  who 
suffered  from  hereditary  syphilis  at  their  birth.  He  thinks  that  these 
lesions  were  the  cause  of  rupture  of  the  spleen  in  the  case  of  a  new-born 
child  with  hereditary  syphilis,  the  details  of  which  were  reported  by  Char- 
cot in  ISC)^). 

Affections  of  the  spleen  have  been  studied  also  by  Birch  IlirschfeW  in 
thirty-two  cases  of  hereditary  syphilis.     He  found  the  organ  nuich  enlarged, 

'  Mouvement  tn^d.,  Paris,  23  nov.,  1872. 

2  Zur  pathologischen  Anatomie  der  herod.  Syphilis.  Arch.  d.  llcilk.,  Loi]>/.., 
Feb.  1875. 


760  HEREDITARY    SYPHILIS. 

but  was  unable  with  the  microscope  to  discover  any  abnormality.  The 
spleen  of  a  fiL'tus,  born  in  a  macerated  condition,  was  soft  and  of  a  dirty- 
violet  color.  In  case  of  still-birth  or  of  death  soon  after  birth,  the  density 
of  the  organ  was  increased  and  its  color  was  dark-brown.  Two  forms  of 
lesion  of  the  spleen  are  therefore  recognized  by  Ilirschfeld  :  in  one  the 
organ  is  indurated  and  of  a  dark-bx'own  color:  in  the  other  it  is  soft  and 
pale. 

Lesions  op  the  Pancreas. 

The  changes  in  the  pancreas,  caused  by  hereditary  syphilis  have  been 
recently  studied  by  Osterloh,'  Oedmansson,^  Wegner,'*  and  most  exten- 
sively by  Birch  Ilirschfeld.*  The  last-mentioned  observer  found  in  thir- 
teen syphilitic  children,  who  died  during  or  soon  after  birth,  varying 
degrees  of  morbid  change.  In  the  most  marked  cases  the  organ  was  much 
enlarged,  its  weight  was  doubled,  its  tissue  firm,  and,  on  section,  it  pre- 
sented a  glistening  white  appearance,  somewhat  like  that  of  scirrhus,  the 
glandular  substance  being  very  indistinct.  Under  the  microscope,  the 
interstitial  connective  tissue,  especially  between  the  larger  lobules,  was 
found  greatly  increased.  Portions  of  lobules  were  compressed,  and  their 
epithelium  was  atrophied  and  in  a  state  of  fatty  degeneration.  The  vessels 
of  the  interstitial  tissue  were  few,  and  their  walls  were  thickened.  This 
extreme  degree  of  the  process  was  observed  in  seven  cases;  in  six  the 
changes  were  less  perceptible,  aud  the  lobules  could  be  distinctly  seen, 
although  the  oi'gan  was  enlarged  and  rather  denser  than  normal.  The 
head  of  the  organ  was  more  altered  than  the  tail. 

Hirschfeld  thinks  that  this  marked  change  begins  late  in  intra-uterine 
life,  since  it  is  rarely  found  in  macerated  fuetuses  prematurely  born.  The 
most  marked  case  was  that  of  a  child  who  died  five  months  after  birth. 

It  is  not  improbable  that  this  degeneration  of  the  pancreas  is  one  of  the 
chief  causes  of  gastro-intestinal  disturbances  in  hereditary  syphilis. 

Affections  of  the  Kidney. 

Our  knowledge  of  the  condition  of  the  kidney  in  hereditary  syphilis  is 
very  limited.  Lancereaux^  states  that  he  has  found  connective  tissue  ])ro- 
liferation  with  fatty  degeneration  of  the  epithelium  lining  the  tubuli  uri- 
niferi.     The  organs  were  firm  and  of  a  yellow  color.     Bradley^  re[)orts 

'  Mitth.  a.  (I.   Kgl.   Siiclis.   Entbindungsinst.   zu   Dresden.      Quoted  hy   Birch 
Hirschfeld. 

2  Jahresb.  ii.  d.  Leistung.  u.  Fortschr.     18G9,  2  Abth.,  ?>61. 

3  Arch.  f.  path.  Auat   etc.,  Berl.     Band  ^0,  Heft  2,  1870, 

*  Beitr.   zur   path.   Anat.   der.  liered.   Sypli.    Neugeborren.    Arch.   d.    Heilk., 
Leipz.,  Feb.,  1875. 

5  Op.  cit.,  page  420. 

6  Syphilitic  Dropsy  of  the  Kidneys,  Brit.  M.  J.,  bond.,  Feb.  4,  1871. 


AFFECTIONS    OF    THE    TESTICLES.  761 

the  case  of  a  syphilitic  child  four  months  old,  with  dropsy  and  albumi- 
nuria, who  was  cured  by  mercurial  treatment. 

The  most  recent  studies  of  the  pathological  anatomy  of  the  kidney 
affected  by  syphilis  are  by  Parrot.  On  section,  he  found  these  organs 
studded  with  numerous  small  tumors,  varying  in  size  from  a  pin's  head  to 
a  cherry-stone.  The  smallest  were  white,  and  the  larger  were  yellow  at 
their  periphery  and  reddish  in  their  centre.  In  some  spots  there  was 
partial  destruction  of  the  renal  tissue,  and  there  were  also  infarctions. 
The  lesion  consists  of  a  circumscribed  or  diffuse  infiltration  of  round 
embryonic  cells,  with  others  of  fusiform  shape,  into  the  connective  tissue 
framework,  followed  by  compression  or  destruction  of  the  tubules  and 
colloid  degeneration  of  their  epithelium.  In  the  early  stages  of  this  affec- 
tion, the  organs  become  much  enlarged,  and  MoUiere  reports  a  case  in 
wdiich  they  were  found  to  be  twice  their  normal  size.  Gradual  atrophy 
follows  degenerations  of  the  new  cells,  and  the  organs  may  finally  become 
much  reduced  in  size. 

Affectioxs  of  the  Suprarenal  Capsules. 

Lancereaux  has  noted  enlargement  of  these  organs  in  a  large  number  of 
cases.  Virchow  has  also  observed  it,  and  speaks  of  a  case  in  which  com- 
plete fatty  degeneration  was  found,  a  condition  met  with  also  by  Hulke. 
According  to  Lancereaux,  proliferation  of  young  connective- tissue  cells  in 
the  cortical  substance  has  been  found  by  Baerensprung.  In  a  case  in 
which  the  left  suprarenal  capsule  was  enlarged  and  adherent  to  the  dia- 
phragm, Hennig  found  its  contents  gelatinous. 

Affections  of  the  Testicles. 

Observation  has  convinced  us  that  Zeissl,  Hill,  and  other  authors  are 
incorrect  in  their  opinion  that  the  testicles  are  not  affected  in  hereditary 
syphilis.  In  a  recent  paper,  we  gave  the  histories  of  five  cases  of  disease 
of  the  testis  in  young  children,  with  marked  lesions  of  hereditary  syphilis. 
The  details  of  seven  cases  have  been  given  by  Henoch,^  and  others  have 
been  reported  by  Xorth,^  Bryant,*  and  Obedenciere.* 

The  disease  consists  of  a  chronic,  painless  enlargement  of  one  or  both 
testicles,  usually  accompanied  by  hyperaimia  of  the  scrotum  and  a  mode- 
rate amount  of  hydrocele,  the  morbid  process  sometimes  involving  the 
epididymis  and  the  cord.  In  recent  cases,  mercurial  treatment  speedily 
effects  a  cure;  in  cases  of  long  standing  atrophy  may  occur,  or  degenera- 
tion of  the  organ,  with  abscess  of  the  scrotal  wall,  followed  by  fungous 
protrusion.     Microscopic  examination  lias  sliown  connective  tissue  j)rolife- 

'  Ueber  Syphilis  der  Hoden  bei  Kleinercii  Kindein.     Doutscho  Ztschr,  f.  inakt. 
M«d.,loipz.,  No.  11,  1877. 
2  Med.  Times  and  da?..,  Lond.,  1862,  vol.  i.  p.  403.  »  u,;,].,  Dec.  1863. 

*  Bull.  Soc.  de  cliir.  du  Paris,  187">,  p.  140. 


762  HEREDITARY    SYPHILIS. 

ration,  usually  involving  the  whole  organ  and  sometimes  the  tunica  vagi- 
nalis, especially  if  the  disease  has  invaded  the  epididymis.  The  history 
of"  the  child,  the  presence  of  syphilitic  lesions  elsewhere  on  its  body  and 
the  slow  development  of  the  disease,  as  compared  with  a  form  of  cancer 
sometimes  seen  in  the  testicles  of  children,  assist  in  diagnosis. 

Morbid  Anatomy. — The  histology  of  the  diseased  testicle  in  hereditary 
syphilis  has  been  studied  by  Parrot  and  Hutinel.^  The  lesion  is  a  prolife- 
ration, interstitial  or  diffuse,  of  round  embryonic  cells  resembling  white 
blood-corpuscles.  In  the  interstitial  form,  in  which  the  gland  may  or 
not  be  perceptibly  altered,  the  cell-growth  results  in  small  tumors  of  vari- 
ous sizes,  irregularly  placed  around  the  arterioles,  which  traverse  the  tra- 
becule. In  the  diffuse  form,  in  which  the  organ  is  much  enlarged,  a 
similar  cell  growth  is  found  permeating  the  meshes  of  its  connective  tissue 
generally.  The  process  begins  at  the  mediastinum  testis,  follows  the  vessels 
of  the  trabeculaa,  penetrates  between  the  seminiferous  tubules,  and  finally 
results  in  hypertrophy  and  sclerosis  of  the  organ  with  partial  or  entire  oblite- 
ration of  the  tubules,  whose  lining  epithelium  undergoes  granulo-fatty  de- 
generation. Fatty  degeneration  and  final  absorption  of  the  new  growth 
take  place,  resulting  in  atrophy  and,  in  rare  cases,  in  complete  destruction 
of  the  organ.  Probably,  the  cases  which  are  attributed  to  arrest  of  develop- 
ment, in  which  the  testis  is  small  or  entirely  absent,  are  those  in  which 
the  organ  has  been  attacked  in  early  life  by  the  lesions  of  hereditary 
syphilis.  Our  knowledge  of  the  lesions  of  the  ovaries  is  limited  to  the 
statement  of  Parrot  that  in  two  cases  he  found  in  the  substance  of  these 
organs  bluish  spots  with  small  whitish  grains.  It  is  probable  that  they 
may  be  affected  in  a  similar  manner  as  the  testis. 

Affections  of  the  Synovial  Sheaths. 

In  two  cases  of  hereditary  syphilis  under  our  observation  the  extensor 
tendons  of  the  hands  were  involved,  as  indicated  by  marked  fusiform 
swelling  over  the  metacarpal  bones,  of  doughy  consistence  and  freely 
movable  under  the  skin  which  was  slightly  distended  and  reddened.  Its 
development  was  rapid  and  associated  with  other  lesions  particularly 
osseous,  its  subsequent  course  indolent  and  not  appreciably  affected  by 
mercurial  treatment.  In  one  case,  cure  resulted  from  the  application  of  a 
compress  over  a  piece  of  mercurial  plaster,  after  withdrawal  of  the  fluid 
•with  the  hypodermic  needle.  Other  tendinous  sheaths  than  those  of  the 
hands  may  be  affected. 

Affections  of  the  Nails — Onychia. 

The  nails  are  more  frequently  involved  in  hereditary  than  in  acquired 
syphilis.  There  are  two  varieties  of  onychia  ;  the  ulcerative,  which  is  the 
moi'e  frequent,  and  the  nutritive,  due  to  impairment  of  nutrition. 

'  Etude  sur  les  lesions  syphilitiques  dii  testicule  chez  les  jcunes  enfants.  Rev. 
mens,  de  med.  et  de  dur.,  I'aris,  fov.,  1878. 


AFTECTION    OP    THE    THYMUS    GLAND.  763 

Ulcerative  onychia  begins  at  the  side  or  base  of  the  nail,  as  a  papule  or 
pustule  which  soon  ulcerates,  the  process  extending  along  the  concave  base 
of  the  nail  being  limited  indefinitely  to  that  location,  or  along  the  lateral 
margins  and  finally  involving  the  matrix  of  the  nail,  which,  in  the  latter 
case,  is  soon  cast  off.  The  distal  phalanx  becomes  very  painful  and  en- 
larged, the  finger  resembling  in  shape  an  Indian  club.  The  thickened 
everted  edges  of  the  ulcer,  its  sloughy  base  and  sanious  discharge,  and  the 
coppery  luie  of  the  surrounding  skin  are  characteristic. 

This  form  of  onychia  may  be  met  with  alone  or  associated  with  general 
papular  or  ulcerative  eruptions  and  is  most  frequently  seen  during  the  first 
year  or  two  of  the  child's  disease.  In  cases  improperly  treated  it  may  be 
developed  later,  and  though  its  course  is  generally  chronic,  it  may  be 
decidedly  shortened  by  appropriate  treatment.  The  nails  of  the  hands 
seem  to  be  more  often  affected  than  those  of  the  feet. 

The  growth  of  a  deformed  and  useless  nail  or  cicatrization  without  a  new 
nail  may  be  expected  in  severe  and  protracted  cases  not  subjected  to 
treatment.  In  such  cases,  osteitis  of  the  phalanx  may  indicate  amputation. 
The  second  form  of  onychia  is  even  more  chronic  than  the  preceding,  and 
a  much  later  manifestation  of  the  disease.  It  begins  as  a  swelling  at  the 
base  or  around  the  margins  of  the  nail,  of  a  coppery  hue,  which  shades  off 
into  the  surrounding  parts.  At  the  same  time  the  nail  loses  its  smoothness 
and  gloss  and  becomes  thickened,  fissured  and  brittle.  The  nail  has  a 
dirty  white  color,  and  there  is  always  hyperemia  of  tlie  matrix  and  the 
surrounding  parts  with  much  deformity  of  the  phalanx  which  may  not  be 
permanent.  The  nail  may  be  finally  restored  in  a  perfectly  healthy  con- 
dition, and  the  bone  is  usually  not  involved. 

Affectioxs  of  the  Hair. 

The  features  of  alopecia  areata  in  hereditary  syphilis  are  similar  to  tliose 
of  the  acquired  form.  It  occurs  in  connection  with  dermal  lesions  of  the 
scalp,  particularly  pustular,  where  in  consequence  of  its  failure  to  be  con- 
trolled by  mercurial  treatment  we  have  been  disposed  to  consider  it  an 
intercurrent  affection.  In  other  cases  the  dry  condition  of  the  hair  seems 
to  be  a  result  of  the  adynamic  influence  of  syphilis,  rather  tiian  any 
specific  effect.  We  are,  therefore,  inclined  to  doubt  the  existence  of  an 
alopecia  symptomatic  of  hereditary  syphilis,  and  to  regard  the  effect  upon 
the  nutrition  of  the  hair  similar  to  that  of  any  debilitating  disease. 

Affection  of  the  Thymus  Gland. 

Paul  Dubois,^  in  l.S.'jO,  first  called  attention  to  certain  pathological 
changes  which  are  found  in  the  thymus  glands  of  infants  who  are  born 
deiid,  or  who  die  a  few  days  after  birth  from  inherited  syphilis.  Externally, 
the  gland  appears  to  be  normal  in  size,  color,  and  consistency;  but  if  au 

'  Gaz.  mod.  do  Paris,  ISSO,  p.  31)2. 


764  HEREDITARY    SYPHILIS. 

incision  be  made  into  its  substance,  pvessure  will  cause  to  exude  from  the 
cut  surface  a  i'ew  drops  of  yellowish  fluid,  wliicli,  under  the  microscope,  is 
found  to  consist  of  pus.  In  the  cases  observed  by  Dubois,  the  purulent 
matter  was  uniformly  diffused  throughout  the  glandular  tissue ;  but  Depaul,^ 
Webei',^  and  Hecker,^  have  met  with  abscesses  of  the  thymus.  The  thy- 
mus gland  naturally  contains  a  whitish,  viscid  fluid,  which  may,  with  a 
little  care,  be  distinguished  from  the  suppuration  dependent  upon  syphilis. 
Of  five  cases  of  this  lesion  observed  by  Dubois  and  Depaul,  an  eruption  of 
pemphigus  was  present  in  four;  and  in  the  same  number  the  syphilitic 
antecedents  of  the  parents  were  clearly  established. 

The  more  recent  observations  of  Weisflag*  and  Wiederhofen^  have  con- 
firmed the  views  of  Dubois,  which  were  at  one  time  rejected  by  several 
German  authors,  who  claimed  that  Dubois  had  mistaken  the  normal  secre- 
tion of  the  gland  for  pus,  and  that  the  possible  changes  were  not  neces- 
sarily due  to  hereditary  syphilis.  Having  studied  the  literature  of  the 
subject,  as  well  as  the  lesion  itself,  Weisflag  arrives  at  the  following  con- 
clusions :  1.  It  is  certain  that  the  thymus  abscess  described  by  Dubois 
exists  and  although  not  a  constant  symptom  of  hereditary  syphilis,  it  is 
sometimes  met  with.  2.  This  lesion,  associated  with  other  signs  of  con- 
genital syphilis  indicates  that  the  father  or  mother  of  tlie  inftint  suffers  or 
has  suffered  from  syphilis.  3.  It  is  possible,  but  not  proved,  that  this 
aftection  may  exist  in  children  in  whom  there  are  no  symptoms  of  syphilis, 
but  its  existence  renders  the  diagnosis  of  hereditary  syphilis  probable,  even 
if  the  disease  of  the  parents  is  not  |)roved.  4.  Such  is  the  great  similarity 
in  the  appearance  of  pus  and  of  the  secretion  of  the  thymus  that  they  cannot 
always  be  distinguished. 

There  are  no  facts  to  prove  the  theory  of  Lancereaux  that  this  fluid  is 
due  to  the  breaking  down  of  gummy  matei-ial.  It  seems  to  us  more 
probable  that  it  is  due  to  a  degeneration  of  connective  tissue  which  has 
been  newly  formed  in  the  parenchyma  of  the  organ. 

Affections  of  the  Lymphatic  Ganglia. 

General  subacute  adenitis,  invariably  present  in  the  early  stages  of  the 
acquired,  is  always  absent  in  hereditary  syphilis,  and  is  an  important 
feature  in  the  differential  diagnosis.  Swelling  of  the  cervical  ganglia, 
which  often  accompanies  active  lesions  in  the  mouth  and  throat  and  upon 
the  scalp  frequently  results  in  abscess,  particularly  in  cachectic  children, 
when  the  condition  can  be  distinguished  from  struma  only  by  the  history 
of  the  case  and  by  concomitant  symptoms. 

'  Gaz.  med.  de  Paris,  1851. 

2  Beitr,  z.  path.  Anat.  d.  Neugeborenen,  Kiel,  1852,  Band  ii.,  p.  75. 

3  Verliandl.  d.  Gesellsch.  f.  Gebiirtsh,  in  Berl.,  Band  viii.,  p.  117. 

*  Ein  Beitrag  ziir  Kenntniss  dcr  Dubois'schen  Thymus  Abscesse  bei  aiigeborener 
Syphilis.     Inaug.  Dissertation,  Zurich,  1860. 

5  Ueber  Syphilis.  Ueber  Thymus  Abscesse  bei  hereditiirer  Syphilis.  Sej^arat- 
Abdruck  aus  dem  J.  d.  Kiiiderheilk.  Wien,  1852. 


LESIONS    OF    THE    UMBILICAL    VEIN.  765 

On  post-mortem  examination,  Hutchinson  found  the  bronchial  ganglia 
of  a  syphilitic  child,  five  months  old,  infiltrated  with  fibrinous  deposits, 
and  cases  of  infiltration  of  cell  elements,  sometimes  in  tlie  form  of  small 
circumscribed  tumors,  have  been  reported  by  Baerensprung.  The  ganglia 
of  the  gastro-hepatic  omentum  and  mesentery  were  found  most  frequently 
involved,  being  symptomatic  perhaps  of  viscei-al  lesions. 

The  Condition  of  the  Blood. 

No  microscopical  observations  of  the  blood  in  the  various  stages  of 
hereditary  syphilis  have  yet  been  made.  Lancereaux,  one  of  the  first  to 
call  attention  to  the  subject,  remarks  that,  considering  the  number  of 
visceral  afiections,  alteration  in  the  composition  of  the  blood  is  probable. 
Increase  in  its  consistency,  and  effusions,  both  parenchymatous  and  into 
cavities,  have  been  noticed,  es[)ecially  by  Hutchinson  and  Baerensprung. 
In  the  case  of  an  infant  who  died  six  hours  after  birth,  Lancereaux  found 
ecchymoses  under  the  pericranium,  in  the  cellular  tissue,  upon  the  surface 
of  the  lungs  and  in  the  pericardium. 

Affections  of  the  Circulatory  Organs. 

The  condition  of  the  arteries  has  not  been  studied,  and  our  knowledge 
of  that  of  the  veins  is  imperfect.  SchiippeF  has  described  profuse  cell- 
infiltration  into  and  about  the  wall  of  the  portal  vein  under  the  name 
syphilitic  periphlebitis.  Tiie  larger  veins  also  were  surrounded  by  gum- 
matous nodules,  their  lumen  contracted,  and  their  walls  so  thickened  that 
they  felt  like  cords.  These  lesions  were  found  in  three  out  of  thirty  cases 
seen  during  a  period  of  two  and  a  half  years. 

Lancereaux  states  that  the  cardiac  affections  of  hereditary  and  acquired 
syphilis  are  similar.  Rosen  found  a  gummy  tumor  in  the  wall  of  the  left 
ventricle.  Forster'  alludes  to  a  case  of  syphilitic  endocarditis,  whose  origin 
Lancereaux  considers  doubtful;  while  Wagner"  discovered  fibrous  myo- 
carditis in  a  syphilitic  stillborn  infant.  According  to  Lancereaux,*  inter- 
stitial myocarditis  and  muscular  hyperplasia  were  found  in  one  case  by 
Kantzon. 

Lesions  of  the  Umbilical  Vein. 

Oedmansson'  and  Winckel"  found  stenosis  of  the  umbilical  vein  in  tiie 
cord  of  certain  macerated  foetuses  whose  death  was  attributed  to  syphilis. 

»  Arch.  (1.  llcilk.,  Leipzig,  Band  xi,  1870. 

2  Hehrend's  Sypliilidologie,  t.  iii,  p.  24!).  18G0, 

'  Wurzb.  mod.  Ztsclir.,  Band  iv,  18(J3. 

*  Arch.  f.  path.  Anat.,  etc.,  Berlin,  Band  xxxv,  1866. 

*  .ndiresl).  ii.  d.  Leistung.  u.  Fortschr.  d.  gea.  Med.,  Berlin,  1860,  ii  Bd.,  S.  .061, 
from  Nord.  med.,  Arch,  i,  4.     Quoted  hy  IIirsclif<dd. 

6  Ber.  a.  d.  k.  Silchs.  Entbind.-lnst.  in  Dresden,  Leipz.,  S.  307.  Quoted  by 
Hirschfeld. 


766  HEREDITARY    SYPIITLTS. 

The  former  thought  tliat  it  avjis  caused  by  the  atheromatous  process.  Birch 
Hirschfehl,^  who  has  also  observed  tliis  condition,  thinks  that  it  is  due  to 
changes  simihir  to  those  occurring  in  the  arteries  of  the  brain,  as  described 
by  Heubner;  he  also  says  that  it  rarely  coexists  with  osteo-chondritis, 
which  "Wegner  considers  an  absolutely  constant  lesion  in  hereditary  syph- 
ilis. If  the  lesion  of  the  vein  is  actually  caused  by  syphilis,  then  Weg- 
ner's  belief  in  the  constancy  of  the  bone  lesion  must  be  erroneous.  Should 
future  investigation  confirm  the  view  of  Ilirschfeld,  this  lesion  of  the  um- 
bilical vein  must  be  considered  nn  important  element  in  causing  the  death 
of  the  syphilitic  embryo. 

Hemorrhagic  Syphilis  ix  Newborn  Children. 

Sixteen  cases  of  a  somewhat  rare  condition  which  has  been  described 
under  this  head  have  been  reported,  and  we  have  ourselves  met  with  two 
Avell-marked  instances.  The  condition  exists  at  birth  or  appears  soon 
after,  commonly  not  later  than  a  month,  and  is  frequently  the  only  syphi- 
litic symptom  presented.  In  such  cases  our  suspicions  of  its  origin  are 
suggested  by  the  syphilitic  history  of  one  or  botli  parents.  In  other  cases 
undoubted  syphilitic  lesions  coexist. 

The  affection  is  due  to  a  condition  of  hydrtemia  caused  by  syphilis,  in 
which,  after  withdrawal  of  blood  from  a  vessel,  coagulation  takes  place 
imperfectly  or  not  at  all.  It  is  usually  observed  in  children  of  profoundly 
sy[)hilitic  parents.  The  hemorrhages  vary  in  extent  and  severity.  In 
some  instances  there  is  merely  a  limited  subcutaneous  effusion,  especially 
where  the  connective  tissue  is  loose  and  abundant,  and  in  parts  exposed 
to  pressure.  In  other  cases  the  process  takes  place  in  the  substance  or 
on  the  surface  of  mucous  membranes,  and  may  result  even  fatally.  In 
such  cases  trifling  injuries  and  slight  bruises  induce  effusion  of  blood.  A 
fatal  termination  may  be  expected  wlien  the  hemorrhage  occurs  beneath 
the  serous  membrane  and  into  the  substance  of  the  viscera.  Although  the 
prognosis  is  not  absolutely  good  in  any  case,  recovery  has  been  known  to 
follow  the  use  of  proper  treatment. 

Affections  of  the  Bones. 

Our  knowledge  of  the  affections  of  the  bones  in  hereditary  syphilis  has 
been  acquired  chiefly  within  the  past  ten  years.  Previously,  tlie  majority 
of  bone  lesions  were  attributed  to  rickets  or  scrofula.  In  1870  an  im- 
portant contribution  to  this  subject  was  published  by  AVegner,^  of  Berlin, 
in  which  he  described  certain  changes  found  at  the  junctions  of  the  dia- 
physes  and  epiphyses  of  the  long  bones  of  infants  with  hereditary  syphilis. 

'  Beitr.  zur  path.  Anat.  der  hered.  Syphilis  Neugeborenen.  Arch.  d.  Heilk., 
Feb.  1875, 

*  Ueber  hereditare  Kiiockensyplillis  bei  jungen  Kindern.  Arch.  f.  path.  Anat., 
etc.,  Berlin,  Band  1,  1870. 


OSTEO-CHORIDITIS-  767 

Two  years  later  Waldeyer  and  Kbbner'  published  a  paper  in  which  they 
confirmed  Wegner's  discovery,  although  they  differed  with  him  in  their  in- 
terpretation of  tlie  pathological  appearances.  Following  these  German 
observers,  Parrot,' of  Paris,  published  in  1872  an  elaborate  paper,  in  which 
he  gave  many  histological  facts  and  brought  out  one  important  symptom  of 
these  affections.  In  1875  we  published  a  work  containing  a  full  description 
of  these  affections,  their  pathology,  and  a  resume  of  previous  contributions 
concerning  them.' 

The  bones  are  affected  in  various  ways  by  hereditary  syphilis.  In  the 
early  months  of  infancy  the  morbid  ciiange  is  peculiarly  frequent  in  long 
bones  at  the  junction  of  the  epiphysis  with  the  diaphysis.  In  the  first  years 
of  hereditary  syphilis  the  small  bones  of  the  fingers  and  toes  are  also  quite 
frequently  affected,  while  later  on  a  tendency  to  invasion  of  the  shafts  of 
long  bones  and  of  the  surfaces  of  flat  ones  is  noticed.  We  shall  therefore 
describe  the  diapliyso-epiphysal  lesion  under  the  name  osteo-chondriti's 
syphilitica  and  the  affection  of  the  long  bones  under  periostitis.  The 
lesions  of  the  bones  of  the  fingers  and  toes  are  somewhat  peculiar  and  re- 
quire a  separate  description. 

OsTEO-CHONDRiTis — This  affcction  is  claimed  to  be  one  of  the  most 
constant  manifestations  of  hereditary  syphilis.  It  is  often  the  only  one, 
and  frequently  its  presence  decides  the  syphilitic  nature  of  coexisting  lesions. 
A  knowledge  of  the  fact  that  this  affection  is  caused  exclusively  by  syphi- 
lis has  been  of  great  service  in  the  study  of  hereditary  syphilis. 

If  we  remember  that  the  growth  of  the  bone  in  length  takes  place  at 
the  extremity  of  the  shaft,  whei'e  the  epiphysis  is  joined  to  it  by  a  layer  of 
cartilage,  and  that  here  syphilitic  changes  are  most  often  found,  we  shall 
see  how  the  normal  development  of  the  bone  may  be  greatly  perverted  or 
interfered  with. 

The  bones  most  commonly  attacked  are  those  of  the  forearm,  the  leg, 
the  arm,  and  the  thigh.  The  clavicle,  sternum  and  ribs  are  also  attacked, 
as  well  as  the  metacari)al  and  metatarsal  bones.  The  number  of  bones  in- 
volved varies.  It  has  been  noticed  that  in  still-born  infants  and  in  those 
dying  soon  after  birth  the  majority  or  even  all  of  the  long  bones  are  affected. 
It  is  very  exceptional  for  the  victims  of  multiple  bone  lesions  to  survive, 
and  it  is  fair  to  assume  that  the  number  of  bones  attacked  varies  with  the 
intensity  of  the  syphilitic  diathesis. 

In  these  cases  of  osteo-chondritis  we  find  at  the  diaphyso-epiphysal 
junction  a  swelling,  which  may  be  visible,  but  in  fat  children  is  often  im- 
perceptible. On  palpation  the  bone  is  found  to  be  encircled  by  an  abruptly 
limited  collar  or  ring,  which  usually  extends  completely  around.  In  some 
cases  the  entire  epiphysis  may  be  expanded,  with  or  without  a  distinct  ring, 

'  Beitriige  zur  Koniitniss  dor  hcroditareu  Knockensyphilis.  Arcli.  f.  patli. 
Anat.,  fttc,  Berlin,  Band  Iv,  1872. 

2  Arch,  de  physiol.  norm,  ct  patli.,  Paris,  4  ann6e,  1872. 

3  R.  W.  Taylok.  Syphilitic  Lesions  of  the  Osseous  System  in  Infants  and  Young 
Children,  New  York,  1875. 


768  HEREDITARY    SYPHILIS. 

at  its  junction  with  the  siiaft.  Tiie  surface  of  these  swellings  and  rings 
is  generally  smooth  ;  it  may  be  slightly  irregular  but  is  seldom  very  much 
ridged.  AVhen  two  contiguous  bones  are  affected  they  often  seem  to  be 
fused  together.  In  living  children  the  distal  more  often  than  the  proximal 
extremities  have  been  found  aff'ected,  and  the  affection  is  generally  sym- 
metrical, especially  in  very  young  subjects.  In  some  cases,  particularly 
at  the  lower  end  of  the  humerus  and  at  the  upper  end  of  the  tibia  the  lesion 
does  not  surround  the  bone,  but  is  limited  to  a  segment  of  the  diaphyso- 
epiphysal  junction. 

The  swellings  on  the  clavicle  are  usually  found  at  its  sternal  end,  and 
are  sometimes  of  large  size.  Those  of  the  steriuim  are  not  common  in  very 
young  children ;  lesions  of  the  ribs,  which  occur  at  their  junction  with  the 
costal  cartilages,  are  also  infrequent,  and  are  generally  not  as  numerous  or 
symmetrical  as  those  of  rickets. 

These  swellings  may  be  developed  slowly  or  quite  rapidly.  After  reach- 
ing their  full  size,  they  usually  remain  in  an  indolent  condition,  causing 
little  if  any  pain,  and  interfering  but  slightly  with  the  motion  of  the  joint- 
Under  appropriate  treatment  they  promptly  subside.  The  integument 
undergoes  very  little  if  any  change,  and  becomes  tense  and  thin  only  when 
the  tumors  are  exceptionally  large.  The  joints  may  be  secondarily  in- 
volved and  become  the  seat  of  subacute  synovitis,  the  eff"usion  being  slight 
or  extreme.  Those  most  commonly  attacked  are  the  elbow  and  knee  ;  as 
a  rule  the  joints  with  short  epiphyses  are  most  liable  to  hyperaimia  and 
eff"usion.  Pressure,  accompanied  by  internal  treatment,  speedily  disperses 
these  joint  swellings,  which  usually  give  rise  to  but  slight  inconvenience. 

Degenerative  changes  sometimes  take  place  in  these  osseous  lesions.  In 
their  mildest  form  they  consist  simply  of  a  superficial  breaking-down  at 
one  part  of  the  swelling.  "We  first  observe  fluctuation,  soon  followed  by 
ulceration  of  the  skin,  resembling  in  appearance  that  which  occurs  in 
gummy  tumors.  These  necrotic  changes,  however,  may  be  much  more 
active  and  extensive  in  the  bone  than  in  the  cutaneous  ulcer,  which  shows 
very  little  tendency  to  increase  in  size.  The  epiphysis  may  be  entirely 
separated  from  the  shaft,  and,  if  the  superficial  ulcer  is  large,  it  may  be 
extruded.  In  most  cases  where  the  destructive  process  is  extensive,  the 
syphilitic  diathesis  is  intense,  and  a  fatal  termination  ensues.  In  others, 
however,  reparative  changes  of  an  interesting  and  peculiar  character  occur. 

The  intervening  cartilage  having  been  destroyed,  the  diaphysis  is  united 
to  the  shaft  only  by  fibres  of  periosteum.  This  membrane  becomes  much 
thickened  and  forms  a  more  or  less  complete  cylinder  uniting  the  two 
fragments  with  considerable  firmness.  Bony  spiculfe  shoot  from  its  inner 
surfiice  between  the  two  osseous  surfaces,  and  eventually  bony  union  is 
formed.  The  periosteum  continues  thickened  for  a  long  time,  but  gradu- 
ally resumes  its  normal  proportions  as  the  union  between  the  bones  grows 
firmer. 

The  effect  of  these  swellings  upon  the  ultimate  shape  of  the  bone  depends 
on  the  intensity  of  the  morbid  process.     When  resolution  takes  place  the 


OSTEO-CHONDRITIS.  7G9 

nutrition  of  the  bone  is  afterwards  fully  restored  ;  but  in  case  of  destruc- 
tion of  the  intermediate  layer  of  cartilage  the  bone  is  usually  shortened. 
These  lesions  are  usually  found  at  birth  or  within  the  first  month  of  life. 
They  may  appear  later,  even  as  late  as  the  twelfth  year,  when  they  are 
developed  very  slowly,  are  few  in  number,  and  are  unsymmetrical.  The 
occurrence  of  ossification  between  the  segments  of  a  bone  no  doubt  has 
much  influence  upon  the  development  of  the  lesions ;  we  may,  therefore, 
expect  to  see  them  at  the  time  when  bony  union  occurs.  Identical  changes 
have  been  observed  in  children  with  acquired  syphilis,  but  the  affection  in 
such  cases  was  limited  to  a  few  bones  or  even  to  one. 

This  affection  results  from  interference  with  the  nutrition  of  the  bone, 
and  presents  three  stages.  In  tlie  first  the  intermediate  layer  of  cartilage 
is  thickened,  uneven  and  irregular,  and  under  the  microscope  we  find 
simple  increase  of  the  cartilage  cells.  In  the  second  stage  the  cartilage  is 
still  thicker,  and  is  nodulated  on  its  epiphysal  surface,  and  warty  or  papilla- 
form  processes  of  calcified  cartilage  project  into  the  hyaline  matrix,  Weg- 
ner  compares  them  with  the  papilUu  of  tlie  cutis,  on  account  of  their  broad 
bases  and  tapering  ends.  Deposits  of  lime  are  also  found  in  the  hyaline 
matrix  between  these  projections.  On  the  periphery,  the  infiltration  en- 
croaches further  into  the  cartilage  than  at  its  centre.  We  find  when  ex- 
amining the  relations  of  this  calcified  line  to  the  spongy  bone  that  there 
are  corresponding  depressions  into  which  the  spongy  tissue  passes.  Under 
the  microscope  we  find  the  longitudinal  rows  of  cartilage  more  abundant 
than  in  the  first  stage,  and  there  is  very  little  intercellular  substance. 
The  vessels  are  numerous,  and  at  the  line  of  ossification  are  surrounded 
by  a  considerable  quantity  of  connective  tissue.  The  walls  of  the  cavities 
are  broader  at  their  bases  and  are  sclerotic.  In  many  places  an  osteoid 
substance  is  developed  from  the  cartilage  and  from  the  medulla  which 
enters  with  the  vessels.  This  substance  is  found  to  be  in  some  places  true 
bone  which  passes  into  the  s[)ongoid  layer.  Beyond  the  coiiche  chondroide 
we  find  irregularly  distributed  spots  of  calcified  cartilage  forming  a  zone 
of  considerable  breadth.  The  principal  points  in  the  second  stage,  there- 
fore, are  greater  proliferation  of  the  cartilage  cells,  premature  sclerosis  of 
the  intercellular  substance,  formation  of  bony  j)rojections  beyond  the  nor- 
mal layer  and  delay  in  bone  formation  elsewhere  ;  in  other  words,  irregular 
osteo-genesis,  premature  in  some  regions  and  retarded  in  others.  In  the 
third  stage  there  is  a  general  enlargement  of  the  epiphyses,  with  thicken- 
ing of  the  periosteum  and  perichondrium.  Under  the  microscope  the  fol- 
lowing conditions  are  seen :  The  lowermost  layer  of  hyaline  cartilage  is 
bluish  and  transparent ;  this  layer  is  succeeded  by  an  irregular  and  wavy 
layer  with  serrated  processes  and  having  a  grayish-white  color  and  of 
homogeneous  formation.  This  layer  is  brittle  and  can  be  readily  removed. 
Next  to  this  is  placed  a  layer  of  grayish-red  or  yellow  substance,  soft, 
and  sometimes  viscid,  whicli  is  gi'adualiy  lost  in  the  s{)ongy  substance  of 
the  diaphysis.  The  medullary  tissue  of  the  latter  continues  for  some  dis- 
tance, and  instead  of  being  normally  red,  is  gray  or  grayisli-red.  This 
layer  seems  to  destroy  tlie  firm  cohesion  of  the  epiphysis  to  the  shaft.  In 
4'J 


770  HEREDITARY    SYPHILIS. 

this  stage  the  proliferation  of  cartilage  cells  and  the  lime  infiltration  is  ex- 
cessive. In  the  layer  next  to  the  bone  we  see  nucleated  cells,  spindle- 
shaped  cells,  and  granular  detritus.  Waldeyer  and  Kobner  consider  this 
to  be  granulation  tissue  growing  into  the  cartilage  from  the  medulla. 
Wegner,  on  the  contrary,  denies  that  it  is  true  granulation  tissue. 

Periostitis "While  osteo-chrondritis  occurs  in  early  infancy,  perios- 
titis is  a  later  affection,  attacking  the  bones  of  syphilitic  children  who 
have  already  begun  to  walk.  Whether  the  active  use  of  the  bones  has  any 
influence  in  developing  periosteal  inflammation  we  cannot  say  positively, 
although  its  occurrence  in  the  bones  of  the  leg  renders  this  view  probable. 
In  the  majority  of  cases  the  femur  and  tibia  are  first  attacked,  sometimes 
as  early  as  the  second  year,  but  generally  at  the  fourth  or  fifth.  Wlien 
long  bones  are  involved  thus  early,  the  greater  part  of  the  shaft  usually 
sutlers.  Tlie  bone  becomes  very  tender,  and  soon  is  seen  to  be  much  en- 
larged, even  to  twice  or  thrice  its  normal  thickness.  It  seems  bent  ante- 
riorly, producing  marked  deformity.  The  fibula  is  also  sometimes  affected 
and  generally  both  legs  are  attacked.  The  bones  of  the  forearm  are,  next 
to  the  tibia,  most  prone  to  this  disease.  The  earlier  it  appears,  the  more 
likely  is  the  affection  to  involve  both  limbs  symmetrically  :  at  later  periods 
it  may  be  unilateral  and  more  localized,  perhaps  forming  circumscribed 
nodes.  The  skull-bones  are  sometimes  the  seat  of  these  nodes,  which  are 
apt  to  be  quite  large  and  multiple.  In  very  severe  cases  they  sometimes 
break  down  and  form  troublesome  abscesses.  Although  periostitis  usually 
occurs  before  the  twelfth  year,  we  have  seen  it  as  late  as  the  fifteenth  and 
even  the  nineteenth  year. 

Dactylitis  Syphilitica In  the  early  months  of  hereditary  syphilis, 

children  are  often  attacked  by  swelling  of  the  phalanges  and  of  the  meta- 
carpal and  metatarsal  bones.  Tliese  lesions  are  of  the  same  character  as 
those  of  acquired  syphilis.  The  proximal  phalanges  are  most  often  attacked, 
and  the  distal  least  commonly ;  sometimes  all  three  phalanges  are  involved 
at  the  same  time.  The  bones  may  be  enlarged  to  twice  or  thrice  their 
natural  size,  the  deformity,  of  course,  differing  with  the  phalanx  involved. 
One  or  more  bones  of  one  or  of  each  hand  may  be  involved ;  in  one  in- 
stance, we  have  seen  every  phalanx  of  each  hand  swollen.  Sometimes  the 
metacarpal  bones  are  enlarged ;  the  lesion  is  less  frequently  seen  in  the  toes 
and  metatarsal  bones.  The  swellings  progress  slowly  or  with  surprising 
rapidity.  In  their  early  stages  the  integument  is  unchanged  ;  at  a  later 
period  the  overlying  parts  become  inflamed  and  an  abscess  is  formed. 
The  condition  is  well  shown  in  Fig.  133,  taken  from  a  cast  of  one  of  our 
own  patients. 

If  uninfluenced  by  treatment,  these  swellings  run  a  very  chronic  course, 
but  when  treated  early  they  gradually  subside.  In  some  cases  exsection 
of  the  bones  is  required,  but  generally  the  destructive  changes  are  more 
extensive  in  the  skin  than  in  the  bones.  Apparently  hopeless  cases  often 
yield  to  persevering  internal  and  local  treatment,  without  the  necessity  of 


DACTYLITIS    SYPHILITICA. 


771 


an  operation.  At  the  termination  of  the  disease  the  shape  of  the  phalanx 
may  be  restored,  or  it  may  be  lengthened  or  even  very  much  thinned  and 
shortened. 


Fig.  133. 


•.\MW^^^^^^^^^. 


gm^' 


"^^.^.  ' 


^^^^^S^i     "" 


Dactylitis  is  usually  observed  in  very  young  children  ;  it  may  also  occur 
as  late  as  the  twentieth  year.  In  the  latter  case  it  is  usually  preceded  by 
other  osseous  and  articular  lesions.  This  late  form  of  hereditary  dacty- 
litis is  Avell  shown  in  a  case  reported  by  Volkmann,  and  included  in  our 
monograph  on  the  subject.^  The  patient,  a  girl,  having  suffered  from 
various  lesions  of  hereditary  syphilis,  at  the  age  of  fourteen  was  attacked 
by  numerous  osseous  and  articular  lesions.     In  her  sixteenth   year   the 

Fig.  134. 


bones  of  the  liands  were  attacked,  and  she  suffered  from  relapses  in  them 
for  fully  fifteen  years.  Fig.  134  represents  the  appearance  of  the  left  hand. 
On  the  dorsum  was  a  large  smooth  movable  cicatrix,  adjoining  a  small 
retracted  spot  at  the  base  of  the  first  metacarpal  bone,  which  was  atro- 
phied, and  ])roduced  a  marked  shortening  of  tlu;  tlinmb.  The  first  phalanx 
of  the  middle  finger  was  mucli  swollen  and  oblicpicly  perforated  by  a  sinus, 
and  tiie  bone  was  completely  divided  by  a  newly-formed  tissue.     The  two 


'  K.  "\V.  Taylok,  on  Dactylitis  Sypliilitica.     Am.  J.  Syph.  and  Derm.,  .Ian.  1871. 


772  HEREDITARY    SYPHILIS. 

phalanges  of  the  thumb,  and  the  first  phalanx  of  the  index  finger,  and  the 
first  phalanx  of  the  right  middle  toe  were  swollen,  but  there  was  no  sinus 
nor  solution  of  continuity  of  the  Jjone.     The  right   hand  (see  Fig.  135) 

Fig.  135. 


showed  the  progress  of  destructive  changes  in  the  bones.  The  first  pha- 
lanx of  the  index  finger  was  shortened  and  seemed  to  be  divided  into  two 
pieces,  so  that  the  patient  had  to  wear  a  glove  to  counteract  the  mobility 
of  the  finger.  The  other  two  phalanges  were  normal.  The  middle  finger 
was  much  attenuated;  the  second  phalanx  was  in  a  position  of  super- 
extension, w^hile  the  first  was  slightly  flexed.  The  bones,  unchanged  in 
form,  were  atrophied,  and  the  integument,  joints  and  tendons  were  normal. 
The  early  form  of  dactylitis  is  more  purely  inflammatory,  while  the  later 
forms  are  due  to  gummatous  infiltration  and  resemble  tlie  bone  lesions  of 
acquired  syphilis  in  their  course  and  results. 

Saveixings  of  the  Metacarpal  and  Metatarsal  Bones These 

lesions  usually  occur  quite  early  in  hereditary  syphilis,  and  may  or  may 
not  coexist  with  dactylitic  enlargemi3nts.  Tliey  may  appear  even  as  late 
as  the  twentieth  year.  A  single  bone  only  is  sometimes  aflected,  but  in 
one  instance  we  have  found  all  of  the  metacarpal  and  metatarsal  bones 
involved.  The  accompanying  figure  (Fig.  13G)  shows  the  appearances 
presented  in  one  of  our  cases,  in  which  the  first  metacarpal  bone  of  the 
right  hand  was  swollen.  These  swellings  usually  form  rapidly  and  attain 
considerable  size.  They  may  or  may  not  be  attended  by  pain.  In  the 
early  years  of  hereditary  syphilis  they  commonly  involve  the  entire  bone, 
in  later  years  the  swellings  are  often  circumscribed.  They  do  not  occur 
as  early  or  as  frequently  as  the  dactylitic  swellings,  nor  have  we  observed 
the  necrotic  tendency  sometimes  seen  in  swellings  of  the  {)lialanges.  When 
the  tumors  reach  a  large  size  the  integument  becomes  tense,  inflamed,  and 
may  ulcerate.     Such  cases  are  very  protra(!ted. 

These  lesions  have  diflferent  results  in  various  cases,  and  according  to 
the  age  of  the  patient.  In  very  young  children  the  bones  may  be  left  in 
a  normal  condition  ;  sometimes  they  are  a  little  thinned  or  shortened.     In 


SWELLINGS    OF    METACARPAL    AND    METATARSAL    BONES        773 

later  stages  of  hereditary  syphilis  we  find  destruction  of  a  segment  of  the 
bone,  which  is  thus  divided  into  two  parts,  joined  finally  by  a  band  of  fibrous 
tissue. 

Fig.  136. 


The  treatment  of  all  bone  swellings  should  combine  mercury  with  iodide 
of  potassium.  We  have  used  in  many  cases,  with  great  benefit,  the  fol- 
lowing : — 


R. 


M. 


Hydrarg.  Biniodidi,  gr.  j        ....  106 

Potass.  lodid.,  ^iv 151 

Syr.  Sars.  Co., 

Aquae,  aa  §ij 60 


Of  this  mixture,  a  child  one  month  old  may  take  five  drops  thrice  daily, 
increasing  the  dose  by  a  drop  every  five  days.  To  a  subject  over  five 
years  of  age,  one-half  of  a  teaspoonful  may  be  given,  and  the  dose  gradu- 
ally increased  to  one  or  one  and  a  half  teaspoonfuls.  Externally,  a  mild 
mercurial  ointment  may  be  used,  or,  better  still,  the  following  ointment 
may  be  kept  in  contact  with  the  affected  parts  under  pressure: — 

^.     Ung.  Hydrarg.  Fort.,  | 

Ung.  Zinci  Oxid.,  aa  Jss 15 

Bals.  Teiu.,  5j 4| 


M. 


Ulcerations  of  tlie  skin  require  appropriate  treatment, 
of  graduated  pressure  should  not  be  forgotten. 


The  advantages 


Affections  of  the  Joints. 

In  some  cases  of  diapliyso-epiphysial  inflammation  (osteo-chondritis) 
occurring  in  hereditary  syphilis,  particularly  when  the  epiphy.ses  are  very 
short,  as  in  the  humerus  and  tibia,  the  neighboring  joint  becomes  the  seat 


774  HEREDITARY    SYPHILIS. 

of  effusion.  In  the  few  cases  of  this  complicfition  which  we  have  observed, 
the  hydrarthrosis  has  taken  place  quite  rapidly,  decided  evidences  of  effu- 
sion existing  in  a  week  or  two.  The  symptoms  are  subacute.  There  is 
but  little  pain  and  not  much  heat,  though  there  may  be  much  swelling  and 
tension  of  the  parts.  The  absorption  of  the  fluid  coincides  with  the  sub- 
sidence of  the  bone  lesion,  and  finally  the  function  of  the  joint  may  be 
fully  restored.  While  the  effusion  exists  the  use  of  the  joint  is  more  or 
less  impaired,  but  degenerative  changes  are  uncommon  in  early  years,  and 
permanent  disability  of  the  joint  is  rare.  Late  affections,  on  the  contrary, 
are  sometimes  attended  by  destructive  changes.  The  elbow,  knee,  wrist, 
shoulder  and  ankle-joints  are  those  most  commonly  affected.  In  some 
cases  the  metatarso-  or  metacarpo-phalangeal,  or  the  carpal  and  tarsal 
joints  are  the  seat  of  hydrarthrosis. 

In  later  years  the  larger  joints  are  sometimes  attacked,  the  affection  in 
some  cases  being  secondary  to  bone  lesions,  in  others  beginning  in  the 
joint.  In  such  instances  we  find  most  decided  change  in  the  synovial 
membrane,  probably  originating  in  the  subsynovial  connective  tissue,  and 
frequently  thickening  of  the  fibrous  capsule  of  the  joint.  The  affection  is 
slow  and  subacute,  but  the  swelling  of  the  joint  is  often  very  great.  Heat 
and  redness  of  the  integument  are  absent ;  pain  is  slight,  although  the 
joint  may  be  sensitive  to  pressure  and  on  motion.  It  differs  from  the  so- 
called  scrofulous  affections  in  its  freedom  from  degenerative  changes.  In 
the  latter,  moreover,  the  morbid  process  is  chiefly  intra-articular.  These 
joint  affections  are  amenable  to  treatment  in  their  early  stages;  later,  they 
are  more  rebellious.  They  undergo  slow  involution,  leaving  only  slight 
disorganization  of  the  joint.  They  ai"e  usually  associated  with  some  other 
manifestation  of  hereditary  syphilis,  usually  a  form  of  bone  lesion,  or  some 
affection  of  the  eye,  teeth  or  skin.  They  may  be  unilateral  or  symme- 
trical, and  may  occur  as  early  as  the  first  year  of  life  or  as  late  as  the 
tw^entieth.  The  infra-articular  infiltration  sometimes  bi'eaks  down  and  a 
sinus  is  formed,  wiiich  discharges  for  a  time,  but  finally  closes  under  treat- 
ment. The  treatment  of  syphilitic  synovitis  includes  internal  and  local 
remedies.  Externally,  friction  with  mild  mercurial  ointment  should  be 
used,  and  the  joint  should  be  kept  at  rest  by  means  of  mercurial  plaster, 
or  the  plaster-of- Paris  or  starch  bandage.  The  general  treatment  consists 
of  a  mercurial  salt  combined  with  iodide  of  potassium. 

Affectioxs  of  the  Nervous  System. 

Until  recently  our  knowledge  of  the  affections  of  the  nervous  system 
caused  by  hereditary  syphilis  was  very  fragmentary  and  incomplete. 
Within  the  past  ten  years,  however,  much  has  been  added  by  the  observa- 
tions of  English   physicians,  and  it  is  to  Ilughlings  Jackson,*  Jonathan 

■  The  most  important  articles  are  two  by  Jackson,  tlie  first  entitled,  Cases  of 
Disease  of  the  Nervous  System  in  Patients  the  Subjects  of  Hereditary  Syphilis, 
reprint,  London,  18(j8 ;  and  second,  Nervous  Symptoms  in  Cases  of  Hereditary 
Syphilis,  Journal  of  Mental  Science,  Jan.  1875.     The  views  of  Hutchinson  are  given 


AFFECTIONS  OF  THE  NERVOUS  SYSTEM.  775 

Hutchinson,  T.  Burlow,  and  T.  S.  Dowse  that  we  owe  nearly  all  of  the 
facts  concerning  this  most  important  subject.  It  is  due  beyond  doubt  largely 
to  the  fact  that  nearly  all  affections  of  the  brain  in  infants  and  young 
children  have  been  for  so  long  considered  to  be  of  tubercular  origin  that 
so  little  attention  has  been  paid  to  the  influence  of  hereditary  syphilis  in 
their  causation,  and  though  the  pathological  facts  which  have  been  learned 
concerning  the  effect  of  this  diathesis  are  far  from  complete,  their  sugges- 
tions are  so  comprehensive  that  their  importance  is  greatly  increased. 
This  statement  is  borne  out  by  the  fact  that  we  now  positively  know  that 
in  hereditary  syphilis  there  have  been  found  the  results  of  meningeal  in- 
flammation, such  as  thickening  and  adhesion  of  the  membranes  by  the 
development  of  fibrous  tissue  and  gummy  material,  and  that  the  endoarte- 
ritis  so  frequently  found  in  the  acquired  form  has  also  been  observed  in 
hereditary  syphilis.  Gummata  on  the  membranes  have  also  been  found. 
This  knowledge  is  most  important  and  far-reaching,  since  it  suggests 
strongly  the  probability  that  there  may  occur  during  the  course  of  heredit- 
ary syphilis  the  same  numerous  and  complex  affections  as  are  known  to 
occur  in  the  acquired  form.  As  our  present  knowledge  of  the  clinical 
history  and  of  the  pathology  of  the  several  hereditary  affections  is  not 
complete,  we  can  only  give  a  general  sketch  of  them.  The  observations 
of  Jackson  and  others  have  conclusively  shown  that  hereditarily  syphilitic 
infants  and  young  children  are  liable  to  chorea.  This  may  be  of  a  mild 
and  ephemeral  form,  or  it  may  be  severe.  In  several  cases  it  has  coexisted 
with  hemiplegia,  and  in  others  there  has  been  superadded  epilepsy.  In 
such  cases,  Jackson  thinks  that  the  liemiplegia  is  caused  by  the  plugging 
up  of  the  middle  cerebral  artery,  that  the  chorea  is  due  to  occlusion  of  its 
small  distal  branches,  while  tl;e  epilepsy  is  due  either  to  thickening  of  the 
meninges  or  a  gummous  growth  in  or  near  the  corpus  striatum.  The  oc- 
currence of  epilepsy  alone,  without  hemii)legia,  is  very  fre(iuently  observed 
in  hereditary  syphilis,  either  within  the  years  of  infancy  or  later  on  in 
childhood.  Indeed,  its  evolution  has  been  observed  as  late  as  the  twelfth 
or  fifteenth  year.  So  impressed  is  Jackson  with  the  relation  of  iiereditary 
syphilis  to  e[)ilepsy  that  he  says:  "When  a  cliild  is  brought  to  us  for 
an  affection  so  painfully  obscure  as  general  epilepsy,  it  is  well  to  examine 
the  patient's  brothers  and  sisters  for  signs  of  syphilis."  We  would  add 
even  more,  tliat  tlie  cliild  should  be  thoroughly  examined  to  determine 
whether  it  is  sy[)hilitic.  The  eye  must  be  examined  su[)erficially  and 
deep.  In  such  cases  we  often  find  evidences  of  an  antecedent  keratitis, 
of  choroiditis  and  retinitis;  sometimes  of  optic  neuritis.  Then,  again, 
we  may  find  evidence  in  the  notched  state  of  the  teeth,  in  certain  small 
white  linear  scars  at  the  angles  of  the  mouth,  in  tailing  of  the  nose,  and 
in  a  bow-shaped   condition  of   tiie  tibise.      All  or  some  of  these  symp- 

thrmifliioiit  his  papers  pu])lislic(l  within  ton  years.  Tlio  cases  of  Barlow  are  pub- 
lislifd  in  the  Transactions  of  tlie  Patli()l<)f,'ical  Society  of  London,  vol.  xxviii,  1877  ; 
and  the  observations  of  D(j\vsk  are  to  Ijc  found  in  his  recent  work  on  the  Brain  and 
its  Diseases,  London,  1879. 


776  HEREDITARY    SYPHILIS. 

toms  may  be  found  also  in  cases  of  epileptic  hemiplegia,  or  of  hemiplegia 
alone.  Though  palsies  of  the  cranial  nerves  do  not  occur  as  frequently  in 
hereditary  as  in  acquired  syphilis,  the  observations  of  Barlow  and  Dowse 
have  positively  proved  that  several  of  them  may  be  attacked  by  syphilis. 
One  of  the  most  suggestive  cases  published  is  that  of  Barlow,  of  an  heredi- 
tarily syphilitic  child  four  months  old,  wiio  presented  well-marked  lesions 
which  were  improved  by  mercury.  Then  she  began  to  run  down,  had 
carpo-pedal  contractions,  was  attacked  by  convulsions  and  died.  At  the 
autopsy  the  membranes  were  found  to  be  slightly  thickened,  and  at  the 
base  at  the  optic  commissure  was  a  small  patch  of  greenish  lymph,  while 
tlie  fissures  of  Sylvius  were  glued  by  old  exudation.  In  many  places  on 
the  vertex,  and  on  the  inferior  surface  of  the  temporo-sphenoidal  lobes, 
there  was  thickening  of  the  membrane  from  fibrous  tissue,  while  on  the 
upper  surface  of  the  left  parietal  lobe  was  a  thin  patch  of  calcification. 
The  small  vessels  of  the  cortex  were  markedly  altered,  being  at  first 
natural,  they  became  of  a  dirty-white  color,  Avithout  dilatation  or  narrow- 
ing, and  looked,  like  threads.  There  was  no  granulation  of  the  pia  mater  as 
in  tubercle.  There  were  also  a  few  patches  of  superficial  softening.  The 
choroid  and  retina  were  infiltrated  in  a  circumscribed  manner  by  corpuscles 
as  large  as  those  of  pus.  The  most  important  point  found  by  Barlow  was 
in  the  thickened  membranes,  which  contained  an  excess  of  fibrous  tissue 
with  cells,  not  mere  nuclei,  but  well-formed  lymphoid  cells,  each  containing 
a  nucleus  and  sometimes  a  nucleolus.  These  seemed  to  have  no  arrange- 
ment around  the  vessels,  and  retained  their  individuality,  with  no  massing 
into  heaps  and  central  degeneration,  thus  differing  from  tubercle.  In  the 
vessels  there  was  a  new  growth  of  the  inner  coat,  which  narrowed  and  even 
occluded  their  calibre.  This  change  was  intra-vascular  also,  differing  from 
what  occurs  in  tubercle.  In  its  minute  anatomy  it  presented  the  appear- 
ance described  by  Heubner  (see  page  ()4G,  chapter  on  Nervous  Affections). 
Barlow's  second  case  is  fully  as  important  in  its  bearings.  It  was  a  boy 
fifteen  months  old,  suffering  from  paresis  of  the  facial  muscles,  general  but 
not  equal  in  amount.  Occasionally  there  was  a  frown  on  the  left  half  of  the 
forehead,  less  on  the  right.  The  right  eyelid  was  found  to  be  shut  some- 
times while  the  other  remained  open.  When  the  child  cried  its  left  cheek 
remained  flat  but  there  was  no  distortion  when  at  rest.  There  were  fre- 
(pient  fine  tremors  of  the  facial  muscles  of  the  right  side  at  the  corner  of 
the  mouth  and  of  the  orbicularis  palpebrarum  and  decidedly  less  on  the 
left  side.  Tlie  child  had  frequent  laryngeal  spasms  but  no  convulsions. 
It  was  thought  that  the  reaction  of  the  muscles  of  both  sides  to  the  constant 
current  was  increased  while  that  to  the  faradic  current  was  diminished. 
During  life  the  case  was  wrongly  diagnosticated  as  of  tubercular  origin. 
At  the  autopsy  four  stellate  patches  of  thin  cicatricial  tissue  were  found  on 
the  liver  and  a  similar  patch  on  the  spleen.  In  the  brain,  the  pia  mater  at 
the  base  was  slightly  opaque  ;  both  third  nerves  were  swollen  out  into  small 
conical  tumors.  There  was  also  swelling  of  the  4th,  5th,  Gth,  7th,  and  8th, 
})airs  causing  a  broadening  there  at  their  superficial  origin.  Mici'oscropic 
examination  showed  atropliy  of  the  nerve  cylinders  and  here  and  there  in 


AFFECTIONS    OF    THE    NERVOUS    SYSTEM.  777 

certain  sections  were  found  round  bodies  resembling  corpora  amylacea. 
There  was  also  a  most  abundant  infiltration  of  new  cells  with  very  fine 
stroma.  This  latter  was  not  abundant  in  the  interfunicular  spaces,  though 
it  was  noted  that  in  the  substance  of  the  funiculi  themselves  there  was  more 
at  the  periphery  than  at  the  centre.  The  appearances  resembled  somewhat 
those  of  the  nerves  in  anaesthetic  leprosy.  In  this  case  also  changes  were 
found  in  the  arteries  which  were  typically  like  those  described  by  Heubner. 
Barlow  calls  attention  to  the  important  fact  that  the  new  growths  were 
symmetrical.  The  second  of  the  two  cases  of  gummata  or  cranial  nerves 
is  reported  by  Dowse,  who  observed  the  fact  at  the  autopsy  of  a  girl  twelve 
years  old  who  had  suffered  from  serpiginous  ulceration  and  destruction  of 
the  nasal  bones.  Two  years  before  her  death  she  had  a  fit  and  thereafter 
suffered  from  dull  aching  pain  in  the  head  continuous  and  paroxysmal. 
She  then  became  thorougldy  epileptic  and  suffered  from  mental  and  visual 
derangements.  Ophthalmoscopic  examination  showed  advanced  changes 
in  the  tissues.  There  was  anjesthesia  of  the  left  side  of  the  face  and  hy- 
peraisthesia  of  the  right.  The  sixth  and  seventh  nerves  wei'e  paralyzed 
and  the  extremities  were  very  weak.  "  For  days  together  she  would  lie 
in  a  state  of  partial  stupor  apparently  careless  of  all  about  her.  At  other 
times  she  was  so  giddy  that  she  was  unable  to  walk  across  tlie  ward  with- 
out reeling,  and  then  again  she  would  have  a  series  of  epileptic  seizures," 
which  were  followed  by  screaming  and  violence.  During  the  fits,  which 
followed  an  aura  beginning  in  the  left  arm  and  ending  in  the  tongue,  there 
was  rigid  muscular  spasm,  more  of  the  i-ight  than  of  the  left.  She  con- 
tinued to  get  worse,  became  aphasic  and  partially  hemiplegic  and  died. 
In  this  case  Heubner's  endo-arteritis  was  found,  together  with  gummous 
pachymeningitis  and  gummata  on  the  fifth  and  seventh  nerves. 

The  affections  of  the  nervous  system  of  hereditary  syphilis  resemble  in 
their  evolution  and  course  those  of  the  acquired  disease,  in  the  complex 
and  disorderly  association  of  symptoms  and  in  the  frequent  coexistence  of 
eye  affections,  such  as  optic  neuritis,  and  paralyses  of  one  or  more  cranial 
nerves.  In  the  hereditary  form  the  ocular  lesions  are  in  general  more  com- 
plex and  numerous  than  in  the  acquired  form. 

Dowse  remarks  with  much  pertinence  that :  "  probably  before  long,  thanks 
to  the  investigations  of  Heubner,  it  will  be  found  that  many  of  the  con- 
ditions which  are  now  recognized  as  scrofulous  are  really  due  to  albuminoid 
or  protoplasmic  nutritive  changes  the  result  of  arterio-capillary  constriction 
which  originated  in  syphilis.  In  due  time  evidence  will  be  fortlicoming 
to  show  that  these  changes  also  occur  in  the  lymphatic  system,  and  that 
they  are  coexistent  with  the  primitive  states  of  foetal  life.  If  pathology  is 
not  leading  us  astray,  our  deductions  at  the  present  time  are  of  the  greatest 
value  and  importance." 

Tkeatmkxt. 

The  propriety  of  treating  a  pregnant  woman  for  sypliilis  has  bcu'n  the 
subject  of  mucli  discussion,  and  has,  at  times,  been  denied  on  tlie  ground 


778  IIEUEDITARY    SYPHILIS. 

that  mercury  was  a  powerful  cause  of  abortion,  and  that  the  death  and  ex- 
pulsion of  the  foetus  was  more  frequently  due  to  the  administration  of  this 
mineral  than  to  syphilis  itself.  It  would  serve  no  useful  purpose  to  enter 
into  the  arguments  Avhich  have  been  advanced  for  and  against  this  suppo- 
sition ;  suffice  it  to  say  that  modern  surgeons,  with  but  few  exceptions, 
regard  the  fear  referred  to  as  chimerical,  and  believe  that  specific  treat- 
ment of  the  mother  is  the  surest  means  of  prolonging  gestation  to  its  full 
term  and  of  affording  security  to  the  infant  after  birth.  Ricord's  views 
upon  this  subject  are  very  explicit  and  decided.  He  says:  "The  period 
of  gestation  in  women,  far  from  contra-indicating  energetic  treatment, 
demands  increased  attention  and  promptitude  within  the  bounds  of  pru- 
dence. I  have  seen  very  many  more  abortions  among  syphilitic  women 
who  had  not  been  treated,  than  among  those  who,  taken  in  time,  had  been 
subjected  to  methodical  medication." 

There  is  strong  ground  for  believing  that  in  those  cases  in  which  mer- 
curials have  appeared  to  favor  abortion,  they  have  done  so  only  in  conse- 
quence of  their  irritant  effect  ujjon  the  intestinal  canal,  and  not  from  any 
abortive  power  inherent  in  the  remedy  itself.  Thus,  six  cases  reported  by 
Colson^  of  abortion  in  pregnant  women  who  were  subjected  to  mercurial 
treatment,  were  analyzed  by  Berlin,^  who  showed  that  in  four  there  was 
violent  vomiting,  and  in  a  fifth  convulsions  at  the  sixth  month  of  preg- 
nancy ;  vvhile  in  the  remaining  case  treatment  had  been  commenced  only 
a  fortnight  before,  and  sufficient  time  had  not  elapsed  to  obtain  its  full 
effect ;  hence,  that  in  none  was  there  reason  to  ascribe  the  death  of  the 
foetus  to  the  judicious  employment  of  mercury. 

The  sympathy  existing  between  the  intestinal  canal  and  the  uterus  is 
well  known,  and  in  the  treatment  of  pregnant  women  affected  with  syphilis, 
we  should  carefully  guard  against  any  irritant  action  u])on  the  stomach  or 
bowels.  Fortunately,  this  end  may  be  accomplished,  and  at  the  same  time 
the  full  action  of  the  remedy  be  obtained  by  mercurial  inunction,  which  is 
by  far  the  best  method  of  treatment  in  such  cjvses.  The  same  opinion  was 
expressed  a  long  time  ago  by  Bell,  who  said :  "  During  pregnancy,  mer- 
cury ought  in  every  instance  to  be  used  in  the  form  of  unction,  as  we 
thereby  with  most  certainty  prevent  it  from  acting  upon  the  stomach  and 
bowels,  and  thus  avoid  the  hazard  of  abortion  taking  place  as  the  effect  of 
irritation  upon  these  parts.  Nothing,  indeed,  more  readily  excites  abor- 
tion than  purgatives  when  severe  in  their  operation  upon  the  bowels,  or 
when  they  even  only  produce  any  considerable  degree  of  tenesmus ;  and 
as  the  internal  exhibition  of  mercury  is  frequently  the  cause  of  this,  it 
cannot  but  with  much  hazard  be  given  in  any  considerable  quantity  during 
])regnancy."* 

When  the  father  is  known  to  have  been  the  subject  of  syphilitic  mani- 
festations at  the  time  of  iin[)regnation,  or  when  previous  abortions  afibrd 

'  Arch.  gen.  de  mdd.,  4e  s^rie,  t.  xviii,  p.  24. 

2  Compte  rendii  dcs  travaux  do  la  Soc.  de  med.  de  Brux.  1858,  p.  82  (as  quoted 
by  Euiile  Vidal,  op.  cit.,  p.  84). 

3  A  Treatise  on  Gonorrhoea  Virulenta,  &c.,  Edinb.,  1793,  vol.  ii,  p.  435. 


TREATMENT.  779 

reason  for  supposing  that  the  disease,  although  apparently  latent  in  him, 
has  still  been  active  enough  to  infect  the  ovum,  it  is  the  part  of  prudence 
to  subject  the  mother  to  treatment  during  pregnancy,  in  the  same  manner 
as  if  she  herself  had  presented  syphilitic  symptoms. 

The  same  method  of  treatment  above  recommended  for  the  mother,  viz., 
mercurial  inunction,  is  no  less  appropriate  for  an  infant  affected  with  con- 
genital syphilis.  The  internal  administration  of  mercury,  as  in  one  of  the 
accompanying  formulae,  will  sometimes  succeed,  but  too  frequently  irritates 
the  bowels,  and,  in  my  own  experience,  affords  far  less  satisfactory  results 
than  the  method  by  inunction. 

I^.     Hydrarg.  .mm  Creta,  gr.  ij-vj       .     112 —     !36 

Sacchari  Albi,  gr.  xij       .     .     .     ,     |75         ! 
M.  et  div.  in  cli.  No.  xii.     One  three  times  a  day. 

I^.     Hydrarg.  Chloridi  | 

Corrosivi,  gr.  ss-j        .     .     .  j03 —      06 

Ammoniae  Muriatis,  gr.  iij        .  20 

Syrupi  Papaveris,  §ij     .     .     .       65, 

Aqua;,  §iv •     120[ 

M.     A  teaspoonful  three  times  a  day. 

Van  Swieten's  solution  and  Plenck's  gummy  mercury^  are  often  used  by 
the  French,  who  also  employ  baths  containing  from  half  a  draciim  to  a 
drachm  of  the  bichloride  of  mercury.  My  own  preferences  are  in  favor  of 
the  gray  powder  for  internal  administration. 

The  advantages  of  mercurial  inunction  and  the  method  of  employing  it 
are  thus  set  forth  by  Sir  Benjamin  Brodie  :'  "  The  mode  in  which  I  have 
treated  these  cases  for  some  years  past  has  been  this  :  I  have  spread  mer- 
curial ointment  made  in  the  proportion  of  a  drachm  to  an  ounce  over  a 
flannel  roller,  and  bound  it  round  the  child  once  a  day.  The  child  kicks 
about,  and  the  cuticle  being  thin,  the  mercury  is  absorbed.  It  does  not 
either  gripe  or  purge,  nor  does  it  make  tlie  gums  sore,  but  it  cures  the  dis- 
ease. I  have  adopted  this  practice  in  a  great  many  cases  with  the  most 
signal  success.  Very  few  children  recover  to  whom  mercury  is  given  in- 
ternally, but  I  have  not  seen  a  case  where  this  method  has  failed." 

Treatment  sliould  by  no  means  be  laid  aside  as  soon  as  all  sy[)hilitic 
manifestations  have  disappejired,  but  should  be  continued  as  a  proi)hylactic 
for  several  months  afterwards. 

Indirect  treatment  by  means  of  remedies  administered  to  the  child's 
nurse  is  not  to  be  depended  upon  in  a  disease  which  makes  such  rapid 
I)rogress,  and  is  so  destructive  in  its  tendency  as  congenital  syphilis.  MM. 
Lutz  and  Personne  have  carefully  analyzed  the  milk  of  nurses  who  were 
subjected  to  mercurial  treatment,  pushed  in  some;  instances  to  salivation, 
without  being  able  to  discover  the  slighest  trace  of  this  mineral.  Exjjeri- 
ments   upon  animals,  however,  have   sliown  that  a  very  minute  quantity 

'  i'l'leiick's  gummy  mercury"  contains  mercury  gr.  xv,  iKiwdcred  gum  Arabic 
gr.  xiv,  and  syrup  of  diacode  (an  electuary  containing  a  small  quantity  of  extract 
of  poppies)  3J.  Triturate  in  a  porcelain  mortar  until  the  mercury  disappears. 
Dose. — '^ss  in  an  appropriate  vehicle.     (Diday.) 

2  Clinical  Lectures  on  Surgery.     Phil,  ed.,  1846,  p.  230. 


780  HEREDITARY    SYPHILIS. 

of  mercury  may  be  detected  in  the  milk  of  a  goat  that  has  been  salivated 
by  mercurial  inunction,  and  cases  have  been  reported  in  which  infants 
have  been  cured  of  syphilis  by  being  fed  upon  milk  derived  from  such  a 
source ;  but  this  method,  for  obvious  reasons,  could  not  be  generally  adopted 
even  if  its  efficacy  were  fully  established. 

In  the  treatment  of  osseous  lesions,  the  use  of  mercury  with  iodide  of 
potassium  is  much  more  effiicacious  than  mercury  alone.  The  combination 
on  which  we  place  most  reliance  is  that  of  the  iodide  of  potassium  with 
the  biniodide  of  mercury,  commonly  called  the  "  mixed  treatment."  To 
children  under  six  months  of  age,  it  is  well  to  give  three  times  daily  ten 
drops,  well  diluted,  of  the  mixture,  the  formula  of  which  is  given  on  page 
773.  This  may  be  increased  by  five  drops  each  week,  until  a  dose  of 
nearly  a  teaspoonful  is  reached.  Gastric  disturbance  is  seldom  caused  by 
prolonged  use  of  this  remedy.  In  some  cases,  when  the  mixed  treatment 
seems  to  have  lost  its  power,  we  have  used,  with  marked  benefit,  the  iodide 
of  potassium  internally  in  connection  with  mercurial  inunction. 

The  local  treatment  of  syphilitic  lesions  is  the  same  in  the  child  as  in 
the  adult,  particular  attention  being  given  to  cleanliness. 


AFFECTIONS    OF    T  El  E    PLACENTA.  781 


CHAPTER    XXVII. 

AFFECTIONS   OF   THE   PLACENTA. 

Our  knowledge  of  the  effects  of  syphilis  upon  the  placenta  is  still  in- 
complete in  many  particulars.  Previous  to  the  publication  of  Virchow's 
lectures  on  tumors,  the  subject  was  little  understood,  and  its  literature 
consisted  only  of  a  number  of  papers  by  various  authors,  in  none  of  which 
was  there  any  approach  to  full  and  scientific  investigation.  In  1873,  how- 
ever, Ernst  FrankeP  published  an  elaborate  article,  reviewing  the  cases 
which  had  already  appeared,  and  giving  the  results  of  his  own  careful 
studies.  An  abstract  of  his  paper  will  give  a  better  idea  of  tlie  subject 
than  it  is  possible  to  offer  in  any  other  manner. 

Friinkel  believes  that  our  want  of  knowledge  of  plancental  syphilis  has 
been  due  in  a  measure  to  the  attempt  to  include  all  cases  under  a  single 
form,  and  that  the  portion  of  the  placenta  fix'st  affected  must  vary,  accord- 
ing as  the  father  is  alone  syphilitic,  and  according  as  the  mother  contracted 
syphilis  before  conception  or  shortly  after  ;"  and  finally,  that  the  foetus  can 
be  but  little,  if  at  all,  affected  if  the  mother  contracts  the  disease  late  in 
pregnancy. 

Virchow  admits  two  forms  of  placental,  affection  : — 

Endometritis  decidualis. 

Endometritis  placentaris. 

To  these  Frankel  adds  a  third — 

Disease  of  the  villous  portion  of  the  foetal  placenta. 

Frankel  founds  his  conclusions  on  the  examination  of  over  one  hun- 
dred placentae,  including  those  of  still-births,  those  of  abortion  and  those 
of  mothers  having  recent  or  old  syphilis.  The  histories  of  the  father  and 
mother  were  obtained  whenever  possible,  and  a  record  of  tiie  macroscopic 
and  microscopic  appearances  was  kept.  Tlie  post-mortem  examinations 
of  the  foetus  were  made  by  Prof.  Waldeyer  and  his  assistant. 

He  groups  his  cases  into  the  following  classes : — 

A.  Disease  of  the  villi  of  tlie  fuital  placenta. 

B.  Mixed  form  of  placental  disease,  the  disease  of  the  villi  encroaching 
upon  the  adjacent  portions  of  the  placenta  materna. 

C.  Disease  of  the  foetus  only,  without  involvement  of  the  placenta. 

'JJeber  Placentar-Sypbilis  ;  Arch.  f.  (fyii.Tk.,  BorL,  B.  V.,  ss.  l-r)4,  1873. 

2  It  will  be  sfiftii  that  Fiiiiikcl  l)elioves  in  tlic  transmission  of  syphilis  fronj  the 
mother  to  tlie  fa-tus  through  the  placental  circulation,  tin;  possibility  of  which,  wo 
have  denied.     We,  however,  leave  Friinkel'.s  views,  uuchangtd. 


782  AFFECTIONS    OF    THE    PLACENTA. 

D.  Primary  disease  of  the  placenta  niaterna  (endometritis  placentaris 
gummosa). 

The  characteristic  lesions  of  the  placenta  are  changes  in  Aolume,  weight 
and  consistency,  and,  microscopically,  the  thick,  plump  form  of  the  foetal 
villosities,  which  is  due  to  the  filling  up  of  the  villous  spaces  with  an 
abundant  proliferation  of  moderately-sized  cells  proceeding  from  the  blood- 
vessels, complicated  with  a  proliferation  of  the  cell-contents  of  the  villi. 
Obliteration  of  the  bloodvessels,  and,  finally,  complete  destruction  of  the 
villi  ensue.  This  aifection  may  appropriately  be  called  "  Deforming  Pi'O- 
liferation  of  Granulation  Cells  of  the  Placental  Villi." 

The  following  is  a  more  detailed  description  of  the  above  changes : — 

Macroscopic  Appearances. — Increased  size  and  weight  (up  to  1000 
grammes)  of  the  placenta  in  strong  contrast  to  the  slight  development  of 
the  fcetus. 

Closer  and  firmer  texture  of  the  placental  tissue,  yet  differing  from  that 
of  old  extravasations  of  blood  and  fibrinous  nodules.  Color  pale  yellow- 
ish-gray, resembling  gray  nerve  matter ;  this  color  was  uniformly  diffused 
in  some  cases;  in  others,  it  was  circumscribed  in  larger  or  smaller  wedge- 
shaped  processes,  extending  from  the  uterine  surface  towards  the  foetus. 
A  point  of  special  importance  was  the  constant  marked  opacity  of  this 
abnormally  colored  portion  of  the  placenta,  especially  noticeable  in  the 
circumscribed  form.  In  this  latter  case  the  healthy  villous  tissue  which 
lay  between  these  portions  was  markedly  hyperjemic  and  livid  in  its 
color  near  the  transitional  portion.  Old  and  recent  extravasations  of 
blood  in  all  stages,  from  organized  fibrin  to  cysts  of  dark  grumous  blood, 
were  also  found. 

The  uterine  surface  of  the  placenta  had  indistinct,  faded,  patchwork 
appearances,  which  was  due  to  opacity  and  thickening  of  the  decidual 
covering.  The  color  was  often  yellowish-gray.  Immediately  beneath 
these  spots  lay  the  wedge-shaped  processes  or  areas  above  referred  to,  and 
when  the  latter  extended  to  the  foetal  surface  they  also  appeared  of  a 
yellowish  color  through  the  chorial  covering. 

The  amnion  and  chorion  were  thickened  and  rendered  opaque  by  deposits 
of  finely  granular  masses,  and  they  were  adherent  to  each  other  in  spots, 
which  were  occasionally  the  seat  of  extravasatcd  blood.  The  umbilical 
arteries  were  only  once  atheromatous  to  any  extent ;  their  intima  was 
colored  yellow,  fatty,  and  thickened  ;  this  change,  however,  extended  but 
a  short  distance  from  the  placenta  towards  the  fcetus.  On  the  fcetal  sui-- 
face  of  the  placenta,  in  many  cases,  were  numerous  miliary  whitish 
nodules  about  the  size  of  a  hemp-seed,  which  closely  followed  the  course 
of  the  vessels  and  were  simple  hyperplasia  of  the  connective  tissue  of  the 
chorion. 

Microscopic  Appearances In  preparing  specimens  for  the  microscope, 

it  was  first  noticed  that  the  villi  of  the  changed  placenta  required  much 
more  teasing  and  pulling  apart  than  usual.  They  appeared  thickened  and 
opacpie  even  to  the  naked  eye,  and,  under  a  low  power  of  the  microscope, 
it  was  evident  that  tliey  were  swollen,  plump-looking,  irregular  in   their 


AFFECTIONS  OF  THE  PLACENTA.  783 

form  and  bulbous.  Their  ends  were  enlarged  into  knob-like  processes,  and 
the  branches  were  irregularly  formed.  Their  normal  transparency  had 
entirely  disappeared.  They  were  filled  with  round  and  spindle-shaped, 
occasionally  polygonal,  small  and  moderate  sized  cells,  which  were  finely 
granular  and  contained  one  or  two,  and  sometimes  three  nuclei.  These 
cells  were  especially  abundant  in  the  centre  of  the  villous  spaces,  along  the 
axis  where  the  vessels  usually  take  their  course.  In  the  villous  trunks 
and  branches  the  spindle-shaped  cells  predominated ;  in  the  ends  of  the 
villi  the  round  cells.  Many  of  these  cells  were  undergoing  fatty  deo-ene- 
ration,  and  the  villous  space  was  often  filled  by  fatty  and  molecular  de- 
tritus. The  bloodvessels  of  the  villi  were  sometimes  completely  obliterated, 
often  circularly  compressed,  while  again  no  traces  of  them  could  be  found. 

The  epithelium  of  these  villi  was  often  wholly  wanting  ;  when  present,  it 
was  denser  than  usual,  its  cells  strongly  granular  and  opaque.  In  one 
case  the  change  was  confined  to  the  epithelium  alone,  while  the  villous 
space  was  swollen  by  cedematous  transudation  fi-om  the  dilated  villous 
bloodvessels. 

When  healthy  places  still  existed  in  these  placentae,  the  normal  villi 
were  usually  found  near  the  foetal  surface  ;  but  even  these  had  a  stroma 
rich  in  cells,  Avhich  at  the  same  time  exhibited  numerous  connective  tissue 
fibres.  Their  vessels  were  dilated,  tortuous,  very  full  and  ruptured  in 
spots. 

The  most  frequent  complication  of  tliis  change  in  the  villi,  was  extrava- 
sation of  blood,  which  was  either  superficial  or  deeji-seated,  and  which  oc- 
curred in  streaks  along  the  borders  of  the  vessels  or  oftener  still  in  the  form 
of  sharply-defined,  firm  nodules  which  extended  to  one  of  the  placental  sur- 
faces. The  exuded  blood  exhibited  the  most  varied  transitional  stages  ; 
the  inclosed  villi  were  atrophied  and  fatty,  and  degenerated  into  fibrous 
tissue. 

.  In  explanation  of  the  origin  and  course  of  these  changes,  Friinkel  states  : 
Owing  to  the  irritation  caused  by  syphilis,  proliferation,  in  a  greater  or 
less  number  of  villi,  begins  in  the  cells,  which,  in  tlie  normal  stroma  of 
the  villi,  are  only  sparingly  found.  Their  nuclei,  and  still  later  the  cells 
themselves,  undergo  manifold  division  ;  and  the  increase  in  number  of  the 
cells  is  attended  by  an  increase  in  tlieir  size.  This  proliferation  is  chiefly 
seated  about  the  vessels  of  the  villi,  and  about  the  deeper  ones  of  the  paren- 
chyma, as  well  as  around  the  more  superficial  and  also  about  the  fine 
capillary  network  lying  directly  beneath  the  ei)itlielium. 

Homologous  products  arise  in  every  tissue  of  the  villus  in  consequence 
of  this  hyperplasia, — cell-proliferation  of  connective  tissue  in  the  stroma, 
epithelial  proliferation  in  the  epithelial  covering.  The  cell-proliferation 
causes  compression  of  the  vessels,  interferes  with  the  circulation,  and  finally 
leads  to  thickening  of  their  walls  and  obliteration  of  the  vessels  themselves. 
The  villi  themselves  are  filled  up  with  cells,  become  hyper-distended, 
plirnip  and  thickened.  The  vascular  spaces  into  which  they  dip,  become 
filled  up  and  narrowed,  and  in  the  most  advanced  stage  they  entirely 
disappear.      By  this  means  and  by  tiie  proliferation  and  thickening  of  the 


784  AFFECTIONS    OF    THE    PLACENTA. 

epithelial  covering,  the  interchange  between  the  maternal  and  foetal  blood 
is  interfered  with,  and  finally  is  wholly  obstructed.  The  villi,  having  thus 
lost  their  iunction,  undergo  fatty  degeneration.  The  cells  of  the  stroma 
and  epitlielium  become  filled  with  fat  granules  and  finally  break  down  into 
granular  matter. 

If  the  process  is  diffuse  and  continuous  over  the  whole  placenta,  the 
foetus  has  in  the  mean  time  perished  ;  if  limited  to  circumscribed  foci,  it 
may  have  continued  to  live.  In  the  latter  case,  the  degeneration  fre- 
quently appears  to  have  advanced  from  the  uterine  toward  the  foetal  sur- 
face ;  the  contrary,  liowever,  has  been  noted.  The  relatively  healthy 
portions  of  the  placenta  between  the  diseased  parts  are  the  seat  of  deep 
congestion  ;  their  bloodvessels  are  dilated  and  gorged  with  blood.  Ex- 
travasations of  blood  in  all  stages  of  retrograde  change  occur,  and  now  and 
then  connective  tissue  formation  in  the  interstitial  tissue  is  superadded. 
Thickening  of  the  intima  of  the  umbilical  vessels  has  been  found  but  once 
by  FrJinkel,  who  considers  it  the  result  of  the  resistance  met  with  by  the 
circulation  in  the  deformed  and  compressed  villi,  and  not  a  truly  syphilitic 
lesion.  Although  this  process  might  be  considered  a  chronic  inflammation 
or  one  due  to  new  formation  of  granulation  tissue,  yet,  on  the  whole,  it 
must  be  conceded  that  it  begins  as,  and  runs  the  course  of,  a  chronic  in- 
flammatory process. 

The  reasons  for  calling  this  lesion  syphilitic  are  : — • 

1.  It  was  found  in  all  of  Frankel's  cases,  in  which  autopsies  showed  the 
existence  of  syphilitic  lesions  of  the  bones  in  tlie  foetus. 

2.  The  proof  of  the  existence  of  syphilis  in  the  parents  in  many  cases. 

3.  That  the  lesion  was  not  due  to  the  death  of  the  foetus,  is  shown  by 
its  existence  in  several  cases  in  which  the  foetus  was  living. 

4.  Absence  of  this  lesion  in  every  other  case  of  diseased  placenta  ever 
examined  by  Frankel. 

5.  Club-shaped  hypertrophy  and  cell-infiltration  is  a  constant  accom- 
paniment of  syphilis. 

Pi-edisposing  causes It  appears  that  this  condition  of  the  villi  is  de- 
veloped, even  if  the  health  of  the  mother  is  in  a  fair  condition  at  the  time 
of  conception,  and  that  it  is  certainly  due  to  a  direct  transfer  of  the  paternal 
syphilis  to  the  ffctus,  as  shown  by  the  fact  that  its.  almost  exclusive  seat  is 
in  tlie  f(Etal  portion  of  tlie  placenta,  the  maternal  portion  not  always  pre- 
senting the  ciiaracteristic  appearances. 

It  may  be  objected  that  the  ovum  may  have  been  infected  through  dis- 
eased ovaries  on  the  part  of  the  mother  without  any  lesion  of  the  remainder 
of  the  genital  tract.     To  this  it  is  to  be  said  : — 

1.  Sy[)hilitic  disease  of  the  ovaries  rarely  occurs. 

2.  In  Frankel's  case  V,  the  disease  existed  in  the  foetal  placenta,  yet 
post-mortem  examination  of  the  mother  failed  to  reveal  any  ovarian  disease. 

o.  In  ease  XVI,  that  of  a  markedly  syphilitic  child,  villous  degenera- 
tion was  present,  together  with  gummous  degeneration  of  the  adjoining 
maternal  tissues,  and  yet  the  decidual  covering  of  the  convex  surface  of 
the  placenta  was  not  involved,  a  portion  whicli   l)y  Winkler  is  considered 


AFFECTIONS    OF    THE    PLACENTA.  785 

"  the  great  highway"  from   the  mother  to   the  foetus   through   the   pla- 
centa. 

Frankel  next  inquires  whether  the  origin,  progress,  and  course  of  the 
disease  can  be  inferred  by  reasoning  from  the  exclusive  seat  of  the  syphi- 
litic affection  in  the  foetus  and  fuetal  portion  of  the  placenta,  taken  in  con- 
nection with  the  history  of  the  case.  Of  17  mothers,  14  were  free  from 
disease  at  and  before  their  confinement ;  1  died,  the  autopsy  revealing  no 
syphilitic  lesion ;  2  mothers  became  diseased,  one  on  the  fifth  day,  the  other 
during  the  fourth  week  after  confinement.  The  lesions  in  the  mothers  before 
confinement  were  :  in  1,  condylomata  lata;  in  1,  psoriasis  at  time  of  con- 
finement, the  chancre  having  been  acquii'ed  in  the  second  month  of  preg- 
nancy ;  in  one,  syphilis  denied,  but  glandular  lesions  afforded  strong  suspi- 
cion. 

Frankel  relates  one  case  in  which  the  maternal  portion  of  the  placenta 
was  primarily  affected.  This  he  calls  "  primary  disease  of  the  placenta 
materna."  (Endometritis  placentaris  gummosa).  The  case  reads  as  fol- 
lows— 

Bertha  B.  has  suffered  since  youth  with  eruptions  and  suppurating  glan- 
dular enlargements.  Has  marked  leucorrhoea  ;  was  never  under  syphilitic 
treatment.  Husband  not  syphilitic.  Now  has  swollen  post-cervical  glands 
and  pigment  spots  on  forehead.  Has  had  five  children  in  five  years ;  one 
macerated  foetus  at  eight  months  ;  one  born  living  which  died  at  the  age  of 
five  weeks  with  ulcers,  etc.  ;  third  and  fourth,  abortions  in  early  months ; 
fifth,  child  born  at  eight  months,  breathed  feebly  and  died  in  half  an  hour. 
Autopsy  of  fifth  child  showed  infant  atrophic,  general  induration  especially 
of  lungs,  liver,  and  spleen.  Spleen  very  large.  Osteochondritis  syphilitica 
present.  Placenta  weighed  480  grammes,  of  a  brownish-red  color  ;  its 
diameters  16  and  15  cms.  ;  thickness  1.3  cm.;  cord  normal.  Convex  sur- 
face of  placenta  covered  bycoagula;  markings  of  lobuli  obliterated  through 
thickening  of  placenta  materna.  Vertical  section  showed  yellowish-gray 
spots  or  nodules  of  the  placenta  materna,  which  seemed  continuous  and  in- 
separable from  the  fijetal  placenta. 

Under  the  microscope,  decidua  showed  slight  and  localized  fatty  degen- 
eration, while  the  thickened  portions  were  the  seat  of  cell  proliferation.  The 
nodules  were  composed  of  connective  tissue,  studded  with  granulation  cells, 
and  their  interior  contained  finely  granular  detritus  but  no  normal  villi. 
The  villi  are  found  between  them  and  com[)ressed  by  them  ;  they  are 
atrophied,  devoiil  of  bloodvessels,  very  fatty,  and  calcified.  Tlief(etus  had 
visceral  and  bone  syphilis,  and  the  mother  suffered  with  syphilis  before  con- 
ception ;  the  direct  influence  of  the  disease  in  the  mother  upon  the  placenta 
is  apparent.  In  the  previous  cases  referred  to,  the  villi  were  the  seat  of 
the  disease,  while  here  it  was  the  maternal  placenta. 

In  all  the  seven  cases  reported  up  to  the  present  time  of  endometritis 
placejitaris  gummosa,  the  mothers  presented  well-marked  sym|)tonis  of 
syphilis,  but  Friinkel  states  that  he  has  met  with  cases  in  which  the  syphi- 
litic mother  had  a  healthy  placenta.  He  tliinks  that  in  these  latter  cases 
the  disease  circulates  through  the  blood  without  leaving  any  trace  of  it  at 
50 


780  AFFECTIONS    OF    THE    PLACENTA. 

any  point,  while  in  other  instances  it  is  localized  in  the  endometrium  and 
is  then  transmitted  to  the  foetus. 

That  syphilitic  endometritis  occurs  is  beyond  question,  it  only  remains 
to  prove  that  this  endometritis  decidua  or  placenta  gummosa  recurs  every 
time  that  an  abortion  takes  place  in  the  same  woman.  In  this  case  the 
fact  of  local  transmission  would  be  established,  and  local  treatment  of  the 
uterine  cavity  would  be  demanded  as  well  as  general  constitutional  treat- 
ment. 

The  influence  iipon  the  foetus  of  placental  disease  is  of  course  prejudicial. 
In  all  seven  cases,  the  infants  were  premature;  six  were  already  macerated, 
and  one,  though  born  alive,  was  so  atrophic  that  it  died  soon  after  birth. 


TREATMENT    OF    SYPHILIS.  787 


CHAPTER   XXVIII. 
TREATMENT   OF    SYPHILIS. 

The  expectant  treatment  of  syphilis  has  been  thoroughly  tried  by  Diday, 
Zeissl,  and  others,  as  it  was  extremelj''  desirable  it  should  be,  in  order  to 
ascertain  what  the  natural  course  of  the  disease  would  be  uninfluenced  by 
medication.  Patients  with  the  early  manifestations  of  secondary  symptoms 
have  been  placed  under  the  best  hygienic  conditions  and  rules  of  diet,  and 
have  received  only  a  placebo  internally  or  some  bland  inunction,  as  of 
cod-liver  oil,  externally,  to  lead  them  to  suppose  that  active  treatment  was 
employed,  while,  in  fact,  only  the  natural  course  of  their  symptoms  was 
watched.  In  some  of  these  cases,  especially  those  in  which  the  symptoms 
were  very  persistent,  the  iodide  of  potassium  was  administered,  but  all 
forms  of  mercury  were  carefully  excluded.  The  result  of  these  trials  has 
been,  as  already  stated,  that  in  very  many  cases  the  disease  tends  to  a 
spontaneous  cure.  The  syphilitic  eruption  and  other  symptoms  disappear 
after  a  while,  to  return  again  very  likely,  but  this  is  no  more  than  we  see 
after  decided  medication  continued  only  for  a  short  period.  Still,  under 
this  purely  expectant  treatment  the  final  result  may  be  most  satisfactory 
and  the  patient  be  left  without  permanent  injury  to  the  health  or  impair- 
ment of  any  organ.  It  is  only  in  a  few  instances  at  this  early  stage  that 
the  administration  of  iodide  of  potassium  has  appeared  to  contribute  to  this 
favorable  result.  But  while  the  above  was  true  of  many  cases,  others 
Avere  met  with  in  which  both  patient  and  surgeon  were  forced  to  renounce 
mere  expectancy,  and  were  only  too  glad  to  have  recourse  to  their  only 
sheet-anchor,  mercury. 

The  expectant  treatment  of  syphilis  will  commend  itself  chiefly  to  those 
who  are  imbued  with  the  vulgar  and  unfounded  prejudice  against  mercury, 
even  when  most  judiciously  administered.  Under  the  expectant  treat- 
ment, the  existing  symptoms  persist  for  a  much  longer  time  than  when 
mercury  is  used,  and  the  patient  continues  to  be  a  focus  of  contagion  to 
tlie  members  of  his  family  and  his  intimate  associates.  If  thus  treated 
unwillingly,  he  is,  moreover,  rendered  impatient  and  despondent  as  he 
sees  some  comrade  rapidly  improving  under  mercurials,  and  is  very  likely 
to  abandon  his  surgeon.  Still  further,  he  is  exposed  to  the  outbreak  of 
serious  manifestations  of  the  disease,  which  may  leave  indelible  marks 
upon  him;  and  we  question  whetlier  his  chances  of  immunity  in  future 
years  from  tertiary  lesions  are  not  greatly  lessened.' 

'  It  may  hero  be  remarked  tliat  Zkissi.,  witliin  tlic  last  few  years,  has  <;ivoii  in 
his  aclliesion  to  the  expectant  treatment,  wliile  Foiunikk  (Le<jniis  sur  la  sypliilis, 
Paris,  1873)  most  ably  and  eloquently  advocates  tiie  use  of  mercury,  prolonged 
for  several  years.     (See  chajiter  on  the  Prognosis  of  Syphilis.) 


788  TREATMENT    OF    SYPHILIS. 

T[ie  treatment  of  sypliilis  which  we  recommend  consists  in  attention 
to  the  general  hygienic  condition  of  the  patient,  and,  as  the  case  demands, 
the  use  of  tonics,  mercurials,  and  the  iodides. 

Hyoiene  and  Tonics The  successful  management  of  any  case  of 

syphilis  undoubtedly  depends  in  a  great  measure  upon  attention  to  hygiene. 
The  most  careful  administration  of  specific  remedies  will  be  of  little  avail, 
unless  the  patient  be  willing  to  submit  to  the  necessary  restrictions  with 
regard  to  diet,  exercise,  exposure,  etc.  Many  syphilitic  patients  who 
enter  our  hospitals  begin  to  im[)rove  at  once,  simply  from  the  fact  that 
they  are  brought  under  better  hygienic  influences,  and  are  obliged  to  lead 
a  regular  course  of  life  and  abstain  from  excesses  which  have  hitherto 
depressed  the  vital  powers  and  thwarted  all  attempts  of  nature  or  of  art  to 
eliminate  the  virus  from  the  system. 

The  essential  features  of  the  hygienic  plan  which  is  adapted  with  slight 
variation  to  nearly  every  case  of  syphilis,  are  general  regularity  of  life, 
simple  but  nourishing  diet,  abstinence  from  the  free  use  of  stimulants  and 
tobacco,  attention  to  the  functions  of  the  skin  and  bowels,  and,  last  but 
not  least,  a  cheerful  disposition.  The  habits  of  the  patient  sliould  be  sys- 
tematic and  regular,  especially  as  regards  his  hours  of  eating,  his  sleep 
and  exercise.  Irregularity  in  these  respects  exercises  a  drain  upon  the 
vital  powers,  the  whole  force  of  which  is  requisite  to  eliminate  the  poison 
from  the  system.  The  diet  should  be  plain  but  nourishing;  plain,  in  order 
that  digestion  may  not  be  too  much  taxed;  sufficiently  Ht»?<r/s/«?'?**7,  that 
nature  may  be  sustained  in  the  work  it  has  to  accomplish,  and  that  the 
depressing  influence  of  the  virus  may  be  counteracted.  It  is  impossible, 
however,  to  give  minute  directions  which  will  be  applicable  to  all  cases, 
when  the  condition  of  different  persons  is  so  various,  and  when  so  much 
must  necessarily  be  left  to  the  judgment  of  the  surgeon.  The  abstemious- 
ness recommended  in  certain  methodical  modes  of  treatment,  as  in  that 
by  Zittmann's  decoction  and  the  dry  treatment  of  the  Aral^ians,^  is  adapted 
for  patients  who  devote  their  whole  time  to  treatment  and  who  lead  an 
inactive  life,  confined  for  the  most  part  to  the  house,  but  will  not  answer 
for  those  who  are  engaged  in  labor  or  the  active  calls  of  business.  Abun- 
dant testimony  proves  that  any  dietetic  course  which  weakens  the  system 
affords  to  syphilis  a  stronger  hold  upon  the  constitution.  When  a  patient, 
the  victim  of  dissipation,  has  for  a  long  series  of  years  been  accustomed  to 
artificial  stimulus  until  it  has  become  a  second  nature  to  him,  it  may  not 
be  best  to  cut  him  off  entirely  from  his  daily  potations,  but  they  should 

'  The  dry  treatment  of  the  Arabians,  as  communicated  by  an  Arab  physician 
who  visited  Marseilles,  is  described  by  M.  Benoit,  who  has  tried  it  with  very  satis- 
factory results,  as  have  also  Lallemand,  Broussonnet,  L.  Boyer,  Tribes,  Jaumes, 
and  Malinowski.  The  patient  is  directed  to  abstain  from  liis  usual  articles  of 
food  ;  lives  on  biscuit,  dried  almonds,  figs,  and  raisins  ;  drinks  only  iji  the  twenty- 
foiir  hours  a  glass  or  two  of  a  decoction  of  sarsaparilla ;  and  takes  a  mercurial 
pill  morning  and  evening. — Gaz.  hebdomadaire,  4  mai,  18G0,  from  the  Montjiellier 
medical,  18(i0,  Nos.  1  et  2. 


HYGIENE    AND    TONICS.  789 

be  given  methodically  under  the  special  supervision  of  the  surgeon,  and  at 
meal  times  rather  than  on  an  empty  stomach.  In  such  cases,  it  is  often 
safer  to  administer  stimulants  in  the  form  of  medicine,  as  the  compound 
tincture  of  gentian;  since  in  this  way  the  necessary  moderation  can  best 
be  secured.  On  the  other  hand,  habitual  high-livers  require  to  be  restricted 
in  the  quantity  and  quality  of  their  food  and  drink,  and  between  these  two 
extremes  every  shade  of  variation  may  be  met  with. 

The  secretions  should  also  receive  attention.  That  of  the  skin  should 
be  promoted  by  regular  exercise  not  carried  to  fatigue,  by  bathing  and 
friction.  The  season  of  the  year,  and  the  habits  and  condition  of  the 
j>atient  will  determine  whether  a  cold  bath  every  morning,  or  a  hot  bath 
two  or  three  times  a  week,  should  be  preferred.  Flannel  or  merino  undei*- 
clothes  should  be  worn  and  changed  fi-equently ;  and  the  bowels  should  be 
opened  at  least  once  a  day.  Absolute  continence  in  men  accustomed  to 
frequent  sexual  indulgence  may  induce  nocturnal  pollutions  and  conse- 
quently be  objectionable,  but  coitus  should  be  pnxctised  only  as  a  relief  to 
the  system  and  never  be  carried  to  excess. 

Tobacco  exercises  a  depressing  influence  upon  the  vital  powers,  and  is 
moreover  objectionable  in  consequence  of  its  irritant  effect  upon  the  mucous 
membrane  of  the  mouth  and  fauces.  Mucous  patches  of  this  region  in 
smokers  and  chewers  are  especially  obstinate,  and  will  often  persist  in 
spite  of  remedies,  unless  the  irritating  cause  be  removed.  Total  abstinence 
from  the  "weed"  should  peremptorily  be  insisted  upon  with  all  syphilitic 
patients. 

The  influence  of  the  mind  upon  the  body  is  rarely  exhibited  in  a  more 
striking  manner  than  in  syphilitic  subjects  ;  those  cases  commonly  proving 
most  intractable,  in  which  patients  are  anxious  and  despondent,  and 
constantly  watching  and  examining  themselves  to  discover  some  new 
symptom.  The  surgeon  is  not  always  blameless  in  this  matter,  for 
promises  of  a  cure  within  a  fixed  time  or  after  a  certain  course  of  treat- 
ment are  almost  sure  to  be  falsified,  and  to  be  followed  by  distippointment 
and  depression  of  spirits.  It  is  therefore  desirable  to  be  frank  at  the 
outset,  and  to  tell  patients  that  no  treatment,  however  thorough  or  pro- 
longed, will  afford  certain  immunity  for  the  future;  that  it  is  the  nature  of 
syphilis  to  manifest  itself  by  repeated  outbreaks ;  that  consequently  the 
reappearance  of  symptoms  is  not  necessarily  to  be  regarded  as  a  relapse; 
that  the  work  of  cure  may  still  be  going  on ;  and  that  with  proper  care  the 
chances  are  strongly  in  favor  of  ultimate  recovery  4ind  com[)lete  restoration 
to  health,  lliere  is  a  disease  ivorse  than  syphilis,  viz.,  syphilophobid^ 
which  has  no  tendency  to  self-limitation,  over  which  remedies  have  no 
control,  and  which  can  only  be  cured  by  the  exercise  of  a  strong  and 
manly  will.^  The  syphilitic  subject  who  would  avoid  this  greater  evil  and 
place  himself  in  the  most  favorable  condition  for  recovery  from  his  actual 

'  I  liave  met  with  three  sad  cases  in  which  syphilomaiiia  has  led  patients  under 
my  charge  to  coiimiit  suicide  several  mouths  after  all  syphilitic  manifestations  liad 
disappeared. 


790  TREATMENT    OF    SYPHILIS. 

disease,  must  shun  gloomy  tlioughts,  give  liis  mind  and  body  healthy 
occupation,  and  cultivate  a  cheertul  disposition. 

Examination  of  the  blood  of  persons  in  the  early  stage  of  syphilis  shows 
a  diminution  of  blood-corpuscles  and  an  increase  in  the  proportion  of  serum. 
This  "  chloro-anjemia,"  as  it  is  very  properly  called,  is  chiefly  confined  to 
the  primary  and  early  stage  of  secondary  symptoms — hence  the  special 
value  of  tonics  at  this  period  of  syphilis;  but  tiiey  are  hardly  less  desirable 
in  the  later  stages  to  counteract  the  depressing  influence  of  the  disease  and 
to  assist  the  action  of  specific  remedies.  Unless  decidedly  contra-indicated 
by  a  plethoric  condition  of  the  patient,  they  should  be  included  in  the 
therapeutic  means  employed  in  all  stages  of  syphilis,  and  they  may  com- 
monly be  administered  with  advantage  for  several  months  after  specific 
remedies  have  been  suspended.  Nearly  all  of  the  mineral  and  vegetable 
tonics  may  in  turn  prove  serviceable.  The  most  useful  are  quinine,  the 
preparations  of  iron,  and  gentian. 

The  chief  i-emedies  in  the  treatment  of  syphilis  are  mercurials,  and 
iodine  and  its  compounds.  The  former  exert  their  therapeutic  action 
mainly  u|)on  secondary  and  the  latter  upon  tertiary  symptoms,  so  that  the 
susceptibility  of  a  given  lesion  to  one  or  the  other  may  in  some  but  not  in 
all  cases  indicate  to  which  stage  of  syphilis  it  belongs.  This  rule,  how- 
ever, is  not  so  invariable  as  the  above  statement  would  make  it  appear, 
and  requires  explanation. 

There  is  no  distinct  line  of  demarcation  in  respect  to  treatment  between 
secondary  and  tertiary  lesions,  but  a  gradual  transition  from  one  to  the 
other.  By  far  the  most  powerful  agent  in  the  treatment  of  the  chancre 
and  the  earlier  general  symptoms  is  mercury ;  as  the  disease  progresses, 
iodine  gradually  begins  to  exercise  a  therapeutic  influence  ;  those  symp- 
toms which  border  upon  the  boundary  line  between  secondary  and  tertiary 
manifestations,  and  which  constitute  the  stage  of  transition — so  called  by 
Ricord — require  a  combination  of  mercury  and  iodine  ;  finally  tertiary 
symptoms  yield  with  great  facility  to  iodine  and  with  difficulty  to  mercury, 
though  it  is  very  doubtful  whetiier  the  former  agent  without  the  assistance 
of  the  latter,  can  effect  their  permanent  removal. 

lite  iodides  cause  tertiary  lesions  rapidly  to  disappear,  hut  do  little  if 
anything  toivards  the  cure  of  the  syphilis. 

Mercurials. — Mercury  came  into  general  use  in  the  treatment  of 
syphilis  within  fifty  years  after  the  appearance  of  the  Italian  epidemic,^ 
ami,  in  spite  of  the  many  attempts  which  have  been  made  to  supplant  it 
by  other  remedies,  still  holds  its  ground  as  the  only  reliable  agent  for 
combating  secondary  lesions.  At  the  present  day  its  efficacy  is  admitted 
both  by  regular  and  irregular  practitioners,  though  the  latter  generally 
administer  it  furtively  and  under  the  guise  of  some  other  name.     It  is  the 

■  HiBSER  (historiscli-pathologische  Untersuchungen,  vol.  i.  p.  230),  accordmg  to 
ViRCHOW,  quotes  a  satirical  poem  composed  by  Georgius  Summarpia,  of  Verona,  in 
1496,  in  which  the  use  of  mercury  in  syphilis  is  mentioned. 


MERCURIALS.  791 

active  ingredient  of  most  of  the  "life-balsams"  and  "  essences  of  sarsapa- 
rilla,"  the  marvellous  virtues  of  which  for  the  cure  of  "  private  diseases" 
are  proclaimed  in  our  daily  and  weekly  journals  (religious  as  well  as  secu- 
lar). Even  the  Homoeopaths  use  it,  in  pretty  full  doses  too,  and  kindly  give 
us  their  approval.  Says  Yeldham  :^  "  It  is  an  interesting  fact  that  the 
practitioners  of  the  old  school  have  arrived  nearer  to  the  truth  in  the 
treatment  of  venereal  than  of  any  other  class  of  diseases." 

When  speaking  of  the  treatment  of  the  chancre  or  initial  lesion  of  syphi- 
lis (p.  469),  the  ground  was  taken  that  it  is  better,  unless  under  certain 
circumstances,  to  defer  the  administration  of  mercury  until  the  appearance 
of  secondary  symptoms.  This  course  is  now  advocated  by  a  number  of 
authorities,  among  whom  are  ZeissP  and  Sigmund.* 

No  one  form  of  mercury  can  be  used  exclusively  in  all  cases  and  in  all 
stages  of  the  disease.  A  preparation  which  agrees  with  one  person  will 
not  unfrequently  disagree  with  another,  and  it  is  sometimes  necessary  to 
make  a  trial  of  several  before  tlie  one  best  adapted  to  the  case  can  be 
selected.  Again,  after  employing  one  form  for  a  time,  when  the  system 
has  become  accustomed  to  it,  it  is  often  desirable  to  change  to  another ;  in 
this  manner  the  therapeutic  action  may  be  increased  without  resorting  to 
large  doses,  which  are  liable  to  disarrange  the  bowels. 

In  general,  my  own  experience  leads  me  to  give  a  decided  preference  to 
mercury  in  the  metallic  form,  as  the  blue  mass  or  mercury  with  chalk, 
above  any  of  its  salts  or  combinations.  At  the  outset,  it  should  be  given 
with  some  degree  of  caution,  since  the  patient's  susceptibility  is  generally 
not  known  before  trial,  and  salivation  is  to  be  avoided.  Contrary  to  a 
very  general  but  mistaken  idea,  at  least  as  applied  to  the  treatment  of 
syphilis,  the  mouth  is  most  readily  affected  by  the  first  mercurial  course  ; 
lience  special  care  should  be  exercised  at  this  time.  The  condition  of  the 
blood  in  early  secondary  syphilis,  already  referred  to,  renders  it  desirable 
to  associate  a  tonic  with  the  mercurial,  as  in  the  following  formula} : — 

I^.     PiluliB  Hydrargyri,  f)ij 2150 

Ferri  Sulphatis  Exsiccati,  9j   •     •     .     •  1  25 

Extract!  Opii,  gr.  v |30 

Mix  and  divide  into  twenty  pills. 

R,     Hydrargyri  cum  CretS,,  ^ij 2150 

Quiniai  SuliJhatis,  ^j l|25 

Mix  and  divide  into  twenty  pills. 
One  of  either  of  these  pills  may  be  given  from  two  to  four  times  a  day. 

"When  there  is  special  reason  for  desiring  speedy  mercurial  action,  a 
combination  of  several  preparations  may  effect  the  purpose  sooner  tiian  one 
alone. 

'  Homoeopathy  in  Venereal  Diseases,  London,  3d  ed.,  p.  10. 

2  Allg.  Wein.'m.-d.  Ztg.,  Nos.  1,  2,  3,  4,  1879. 

3  Wiener  Kliuik,  Oct.  187G. 


'92  TREATMENT    OF    SYPHILIS. 


PiUilse  Hydrargvri,  ^j 1  25 

60 
25 
30 


Ilydrargyi'i  Chloridi  Mitis 
Hydrargvri  cum  Greta,  3j 
Ext.  Opii,  gr.  v. 
M.     In  twenty  pills. 

It  is  best  to  commence  with  one  of  tlie  above  pills  morning  and  night, 
and,  if  no  effect  be  perceptible  by  the  fourth  or  fifth  day,  to  increase  to 
three  a  day.  So  soon  as  the  chancre  begins  to  assume  a  more  healthy 
aspect,  or  the  secondary  symptoms  to  subside,  no  further  change  in  the  treat- 
ment is  required,  unless,  on  the  one  hand,  the  mouth  become  tender,  or, 
on  the  other,  the  symptoms  cease  to  improve ;  in  the  former  case  the 
remedy  must  be  suspended,  and  in  the  latter  given  more  frequently. 

The  dose  of  the  protiodide  is  from  one-sixth  of  a  grain  (0.01)  to  half  a 
grain  (0.03),  given  in  a  pilular  form  two  or  three  times  a  day.  No  bene- 
fit will  be  derived  from  exceeding  the  latter  quantity,  which  alone  is  apt 
to  i)roduce  diarrhoea.  Indeed,  the  chief  objection  to  this  pi'eparation  is 
the  abdominal  pain  and  intestinal  irritation  which  it  often  occasions;  but 
tliese  may  in  most  cases  be  avoided  by  directing  the  patient  to  take  his 
pill  about  an  hour  after  meals,  when  the  stomach  is  not  entirely  empty,  or, 
if  necessary,  by  the  addition  of  opium  ;  if  these  measures  fail,  some  other 
form  of  the  mineral  must  be  employed.  The  sug-ar-coated  granules  of  the 
protiodide,  each  of  which  contains  one-fifth  of  a  grain,  afford  a  very  con- 
venient and  elegant  mode  of  administration,  and,  by  their  minute  division, 
enable  the  surgeon  to  graduate  the  dose  from  day  to  day  according  to  the 
exigencies  of  the  case.  The  first  decimal  trituration,  i.  e.,  one  part  to  nine 
parts  of  sugar  of  milk,  as  prepared  by  the  homoeopaths,  is  also  to  be  recom- 
mended on  account  of  the  thoroughness  of  the  trituration  and  the  fineness 
of  the  powder,  which  renders  it  less  irritating.  Two  grains  (0.12)  contain, 
of  course,  one-fifth  of  a  grain  (0.012)  of  the  iodide. 

A  convenient  mode  of  exhibiting  the  biniodide  of  mercury  is  by  decom- 
posing the  bichloride  by  means  of  the  iodide  of  potassium,  and  dissolving 
the  precipitated  biniodide  with  an  excess  of  the  iodide  of  potassium,  as  in 
the  following  formula: — 

I^.     Hvdrargyri  Bichloridi,  gr.  ij     .     .     .  (12 

Potassii  lodidi,  3ss      ..'....         2|00 
Aquaj,  iviij 250:00 

M. 
Dose. — A  dessertspoonful  (10.00)  an  hour  after  eating,  two  or  three  times  a  day. 

Gibert's  favorite  formula,  which  is  much  emi)loyed  at  the  Saint  Louis 
and  other  hospitals  of  Paris,  where  it  is  known  as  the  "syrup  of  the  iodu- 
retted  biniodide  of  mercury,"  is  as  follows  : — 


M. 
Dose. — A  tablespoonful  (15.00). 


Hydrargyri  Biniodidi,  gr.  j         ...  0 

Potaasii  lodidi,  3j        4 

Aqu;e,  gj        4 

Filter  through  ])ai)er  and  add — 

Syrupi,  §v 150 


MERCURIALS.  793 

Mr.  Langston  Parker  recommends  the  following: — 

K-     Hydrargyri  Biniodidi,  gr.  iij      .  0l20 

P'otassii'lodidi,  5j-iij   '    .      .     .  4j00— 12100 

Spiritus  Villi,  3j 4!00 

Syruiji  Zingiberis,  3ii.i     •     •     •  1200 

Aquse,  §iss 45  00 

M. 

Dose. — Twenty  to  thirty  drops  (1.50-2.00)  three  times  a  day  in  half  a  tumbler- 
ful of  fluid. 

Such  combinations  of  mercury  and  iodide  of  potassium  are  the  more 
valuable,  the  longer  the  time  which  has  elapsed  since  contagion.  In  late 
secondary  lesions,  we  often  administer  half  a  grain  (0.03)  or  less  of  the 
protiodide  of  mercury  at  noon  and  the  iodide  of  potassium  morning  and 
night.  Duncan's  compressed  pills  of  the  bichloride  of  mercury  and  the 
iodide  of  potassium  are  also  of  value.  They  are  prepared  of  three  dif- 
ferent strengtlis,  containing,  ^^g,  ^^^,  and  J^  o^  '-^  grain  of  the  bichloride, 
with  3,  4,  or  5  grains  of  the  iodide. 

The  bichloride  has  for  a  long  time  been  a  favorite  preparation  with 
many.  It  has  certain  advantages;  in  small  doses  it  rarely  salivates,  and 
its  administration  does  not  require  to  be  so  closely  watched  as  that  of  the 
more  active  forms  of  mercury.  It  is,  tlierefore,  worthy  of  employment  in 
those  patients  who  tolerate  it,  and  wlio  live  at  a  distance  from  their  sur- 
gical attendant;  in  those  who  are  peculiarly  susceptible  to  the  morbid 
action  of  mercury,  and  in  persons  of  a  broken-down  constitution.  Its 
taste,  how^ever,  is  very  repulsive,  and  it  is  not  well  borne  by  delicate  and 
sensitive  stomachs,  often  occasioning  gastric  pain,  cramps,  and  colic.  For 
the  latter  reason,  it  is  better  tolerated  by  men  than  women.  But  there 
are  much  better  preparations  of  mercury  than  this,  and  we  desire  to  pro- 
test against  the  indiscriminate  use  of  the  bichloride,  which  is  the  routine 
practice  of  many  practitioners.  It  has  little  effect  in  subduing  syphilitic 
symptoms,  especially  in  obstinate  cases,  and  patients  are  constantly  brought 
to  us  by  their  attending  pliysicians  in  consultation,  with  the  report  that 
"  the  disease  will  not  yield  to  mercury,"  when  the  only  fault  has  been  the 
choice  of  a  comparatively,  and  frequently  intolerable,  preparation  of  tliis 
mineral. 

The  bicliloride  of  mercury  may  be  administered  in  solution  or  in  a  pill. 
It  is  very  liable  to  undergo  decomposition,  and,  with  the  intention  of 
preventing  this,  is  usually  associated  with  muriate  of  ammonia.  The 
average  dose  for  an  adult  is  one-sixteenth  of  a  grain,  but  is  sometimes 
raised  to  a  fourtli  or  even  lialf  a  grain;  in  the  treatment  of  sypiiilis,  how- 
ever, I  liave  rarely  found  it  beneficial  to  exceed  one-tenth  of  a  grain, 
given  three  times  a  day  upon  a  stomach  not  entirely  empty;  even  in  this 
quantity  it  is  difficult  to  prevent  intestinal  pain  and  irritation. 

This  preparation  of  mercury  was  extensively  used  by  Van  Swieten,'and 
is  the  active  ingredient  of  the  "  liquid"  known  by  his  name,  the  formula 
for  which  is  as  follows  : — 

'  Commentaries,  xvii,  292. 


794  TREATMENT    OF    SYPHILIS. 

I^.     Hydrargyri  Bichloridi,  1  pt. 
Aquse,  900  pt's. 
Spiritus  roct.,  100  pts. 

The  average  dose  of  Van  Swieten's  liquid  is  a  tablespoonful  (15.00), 
which  is  given  in  a  glass  of  sweetened  water. 

The  solubility  of  tlie  bichloride  of  mercury  in  alcohol  and  water  facili- 
tates its  administration  in  any  of  the  vegetable  tinctures  and  infusions 
which  are  often  required  in  aniemic  subjects.  When  given  in  this  form, 
it  doubtless  undergoes  partial  decomposition,  but  does  not  appear  to  lose 
its  therapeutic  effect.  I  sometimes  employ  as  a  menstruum  the  tincture  of 
tlie  chloride  of  iron. 

I^.     Hydrargyri  Bicliloridi, 

Aramonise  Muriatis,  aH  gr.  iij      ...  20 

Tinct.  Ciiichoiiffi  Comp..  §iij   ....     9000 

AquiB  §iij    .....' 90  00 

M. 
From  a  teaspoonful  (5.00)  to  a  tablespoonful  (15.00)  two  or  three  times  a  day. 

I^.     Hydrargyri  Bicliloridi,  gr.  iv      .     .     .         125 
Tiiiot.  Ferri  Chloridi,  5iv       ....     ISJOO 
M. 
Eight  drops  (0.50)  contain  very  nearly  one-sixteenth   (0.004)  of  a  grain  of  the 
bichloride. 

The  pilular  form  is  more  convenient  for  many  persons.  Equal  parts 
of  the  bichloride  oi"  mercury  and  the  muriate  of  ammonia  may  be  dissolved 
in  a  very  small  amount  of  pure  water,  with  which  finely-powdered  cracker 
is  to  be  mixed  in  sufficient  quantity  to  absorb  it ;  syrup  of  gum  acacia  is 
added  to  give  it  consistency,  and  the  mass  rolled  into  pills  containing  the 
desired  quantity  of  the  bichloride.  Extract  of  dandelion  is  also  a  conve- 
nient vehicle,  but  is  more  liable  to  decompose  the  mercurial. 

It  is  a  fact  but  little  known  that  the  bichloride  may  be  administered  in 
cod-liver  oil  by  first  dissolving  it  in  a  few  drops  of  sulphuric  ether.  If  the 
bottle  be  kept  tightly  corked  it  may  be  retained  in  solution  for  an  indefi- 
nite time  ;  but  if  the  ether  be  allowed  to  evaporate  by  exposure  to  the  air, 
the  bichloride  Avill  be  precipitated  and  cannot  be  redissolved  by  the  addition 
of  more  ether. 

I^.     Hydrargyri  Bichloridi,  gr.  ij  .     .     .     .  12 

Etlieris  Sulphuric!,  5) 4  00 

Dissolve  and  adil — 

Olei  Morrhu:e,  5vj 200 

M. 
A  dessertHpoonfiil  (10.00)  contains  one-twelfth  of  a  grain  (0.005)  of  the  bichlo- 
ride. 

The  preparations  of  mercury  above  mentioned  are  those  which  are  found 
to  be  the  most  serviceable  in  the  treatment  of  syphilis,  though  others,  as, 
for  instance,  Plummer's  pill,  may  sometimes  be  employed  to  advantage. 

Increased  experience  in  the  treatment  of  syphilis,  however,  has  led  me 
to  give  a  decided  preference  to  the  external  over  the  internal  use  of  mer- 
cury, in  any  outbreak  of  general  symptoms  subsequent  to  the  first.      In  the 


MERCURIALS.  795 

earliest  attack  of  general  manifestations,  small  doses  of  the  blue  mass,  or 
mercury  with  chalk  are  commonly  sufficient  to  subdue  the  symptoms  with- 
out unpleasant  action  upon  the  gums  or  bowels  ;  but  at  a  subsequent  period 
tolerance  of  the  remedy  has  often  been  acquired  and  the  administration  of 
doses  sufficient  to  accomplish  the  desired  end  will  very  frequently  induce 
diarrhoea,  salivation  or  general  cachexia  ;  while  the  use  of  mercury  by  fumi- 
gation or  inunction  rarely  salivates  or  causes  diarrha^a,  does  not  disarrange 
tlxe  stomach,  and  it  has  appeared  to  me,  has  a  much  more  decided  effect 
upon  the  disease  than  mercury  by  the  mouth.  I  frequently  see  symptoms 
which  have  persisted  for  many  months  under  the  internal  use  of  mercury, 
rapidly  subside  and  disappear  as  the  etfect  of  its  external  application. 

Fumigation ^Mercurial  fumigation  was  employed  at  a  very  early  period 

in  the  treatment  of  syphilis,  but  fell  into  almost  complete  disuse  until  re- 
vived by  Mr.  Langston  Parker,  of  Birmingham,  England.  In  Mr.  Par- 
ker's method,  the  vapor  of  water  is  combined  with  that  of  mercury,  con- 
stituting a  "  moist  mercurial  vapor  bath,"  which  is  regarded  by  its  author 
as  a  means  of  treating  syphilis  "  safer,  quicker,  more  certain,  less  fre- 
quently followed  by  relapses,  and  more  efficient  in  obstinate  cases  than  any 
other." 

The  mercurial  vapor  may  be  generated  from  metallic  mercury,  calomel, 
mercury  with  chalk,  the  bisulphuret,  the  gray  oxide  or  the  binoxide,  from 
a  scruple  (1.25)  to  three  drachms  (12.00)  of  which  are  required  for  each 
bath,  the  quantity  being  proportioned  to  the  effiict  desired.  Mr.  Parker 
states  that  in  skin  diseases,  and  especially  in  rupia,  the  bisulphuret  is  to  be 
preferred  ;  in  diseases  of  the  throat  and  nose,  the  gray  oxide,  binoxide 
or  calomel  is  better,  because  the  patient  can  bear  the  head  immersed 
without  sneezing  or  coughing,  which  he  cannot  do  when  the  bisulphuret  is 
used. 

I  commonly  employ  calomel,  as  recommended  by  Mr.  Henry  Lee,  and  also 
the  lamp  (Fig.  137)  introduced  by  the  same  surgeon,  which  is  a  great  im- 
provement over  the  more  elaborate  and  costly  ap[)aratus  formerly  in  use. 

The  purest  calomel  only  should  be  used,  and  it  is  better  to  have  it  re- 
sublimed  and  then  washed,  so  as  to  rid  it  entirely  of  its  free  hydrochloric 
acid,  the  fumes  of  which  are  very  irritating  to  the  lungs. 

The  best  time  for  taking  the  bath  is  just  before  going  to  bed.  The  cir- 
cular groove  on  the  top  is  to  be  tilled  one-third  full  of  boiling  water,  the 
alcohol  lamp  beneath  lighted,  and,  at  the  last  moment,  about  half  a  drachm 
(2.00)  of  calomel  to  be  deposited  upon  the  plate  C.  The  patient  stripped  of 
his  clothing  and  enveloped  in  one  or  more  bhinkets  drawn  closely  round 
the  neck,  sits  upon  a  cane-bottomed  chair  with  the  lamp  beneath.  In  the 
course  of  five  to  ten  minutes,  profuse  perspiration  is  induced  ;  the  calomel 
is  wholly  evaporated  within  fifteen  to  twenty  minutes,  when  the  lamp  may 
be  blown  out,  and  the  patient,  after  waiting  five  or  ten  minutes  longer 
exj)Osed  to  the  moist  vapor,  may  retire  to  bed.  I  conmionly  advise,  as  re- 
commended by  Mr.  Lee,  that  the  use  of  a  towel  after  the  bath  should  be 
avoided,  so  that  the  thin  layer  of  mercury  deposited  upon  tiie  surface  of 
the  body  may  remain  and  be  further  absorbed.     In   order   to  prevent  too 


79G 


TREATMENT    OF    SYPHILIS. 


sudden  a  change  of  temperature,  it  is  well  for  the  patient  to  remain  en- 
veloped in  the  blanket  on  going  to  bed,  or,  before  immersion,  he  may  put 
on  a  long  flannel  night-gown  whicii  can  be  drawn  up  around  the  neck  until 


Ficr.  r?,', 


Lee's  lamp  for  fumigation.    This  lamp  is  now  made  of  wire  gauze,  and  resembles  the  safety 
lamp  of  tlie  miners,  thereby  guarding  against  sudden  explosions  of  the  alcoholic  vapor. 

he  is  ready  to  retire.  I  have  never,  however,  seen  any  ill  effects  from 
"  taking  cold,"  nor  found  it  necessary  to  restrict  patients  with  regard  to 
exposure  to  the  weather  any  more  than  when  giving  mercury  by  the  mouth. 
When  put  to  bed  it  is  well  to  give  the  patient  a  tumblerful  of  the  compound 
decoction  of  guaiacum  or  sarsaparilla,  as  hot  as  he  can  drink  it. 

My  friend,  the  late  Prof.  F.  F.  Maury,  M.D.,  of  Philadelphia,  invented 
an  apparatus  for  the  same  purpose,  which  may  be  attached  to  any  ordinary 
gas  fixture  ;  and  which  avoids  the  danger  of  using  a  lamp  containing 
alcohol.  (Fig.  138.) 

In  the  absence  of  these  contrivances,  an  excellent  plan  is  to  dissolve  any 
soluble  compound  of  mercury,  as  corrosive  sublimate,  in  water,  and  subject 
the  same  to  ebullition  by  any  ordinary  process  :  or,  a  simple  appsiratus 
may  be  extemporized  by  heating  a  brick  and  sprinkling  the  calomel  upon 
its  surface,  at  the  same  time  placing  a  pail  of  boiling  water  by  its  side 
beneath  the  chair.^ 


•  Prof.  David  W.  Yandcll,  M.D.,  has  published  an  excellent  lecture  on  the 
Mercurial  Vapor-Batli,  which  is  wortli  reading. — Am.  Pract.,  Louisville,  Sept., 
1877. 


MERCURIALS.  797 

The  frequency  of  the  baths  should  be  determined  by  the  strength  of  the 
patient  and  the  degree  of  mercurial  action  desired.  In  cases  of  secondary 
syphilis,  when  the  strength  of  the  patient  is  fair,  every  night  is  not  too 

Fig.  138. 


Prof.  Maury's  apparatns  for  moist  mercuiial  fumigations.  It  consists  of  two  Bunseu's  burner."?, 
one  of  which  is  surmounted  by  a  pan  to  contain  tlie  water,  and  the  other  by  a  small  shallow  dish 
for  the  preparation  of  mercury.  The  ajiparatus  is  attached  by  means  of  a  flexible  tube  to  any 
ordinary  gas  fixture. 

frerpient ;  in  debilitated  subjects  and  in  cases  of  tertiary  syphilis  when 
only  a  slight  effect  from  mercury  is  desired,  from  one  to  three  times  a 
week  is  sufficient.  During  the  period  of  their  administration,  the  patient 
should  wear  flannel  next  tlie  skin  and  observe  the  hygienic  rules  hereto- 
fore laid  down  ;  and  mercury  in  minute  doses,  iodide  of  potassium,  or 
tonics  may  be  given  internally.  The  syphilitic  symptoms  often  exhibit  an 
improvement  after  the  first  or  second  bath  and  generally  disai)pear  in  the 
course  of  from  one  to  three  weeks,  but  the  treatment  should  be  continued 
for  at  least  .some  weeks  longer. 

The  most  fn;quent  complaint  made  l)y  patients  against  this  mode  of 
treatment  is  a  feeling  of  debility,  and  sometimes  headache :  effects  which  I 
believe  to  be  due  to  too  great  an  amount  of  steam.  The  difficulty  may  be 
obviated  by  diminishing  the  amount  of  water,  and  shortening  the  duration 
of  tiie  bath.  If  neces.sary,  so  little  water  may  be  used  that  the  whole  of  it 
will  be  evaporated  in  tiie  course  of  ten  minutes,  after  which  the  force  of 
the  flame  is  expended  upon  the  mercury.     The  gums  frequently  become 


798  TREATMENT    OF    SYPHILIS. 

tender,  but  decided  salivation  is  very  rare.  In  some  instances  the  physi- 
ological effect  of  the  mercury  is  manifested  by  severe  diarrhoea,  such  as 
often  takes  place  after  the  prolonged  internal  use  of  the  mineral. 

We  are  inclined  to  think  that  the  absorption  through  the  skin  is  very 
slio-ht,  and  that  the  effect  is  proportioned  to  the  amount  of  the  mercurial 
vapor  inhaled  by  the  patient.  Certainly  the  effect  is  not  constant :  and 
while  some  patients  bear  the  baths  not  only  with  impunity  but  with  bene- 
fit, others  are  obliged  to  abandon  them  from  the  occurrence  of  salivation, 
headache,  weakness,  etc. 

Mercurial  fumigation  unfortunately  requires  an  amount  of  time  and 
attention  which  few  patients  are  willing  to  devote  to  it,  or  recourse  must 
be  had  to  professional  bath-givers,  whose  inherent  tendency  would  seem  to 
be  to  absorb  the  patient  at  the  same  time  that  he  absorbs  the  mercurial 
fumes. 

Inunction Inunction  is  a  less  cleanly  and,  therefore,  more  disagreeable 

external  mode  of  using  mercury  than  fumigation  ;  but  it  is  more  convenient 
for  most  patients,  and  its  effect  is  even  more  satisfactory.  Sigmund,  who 
used  mercurial  inunctions  in  9379  cases,  occurring  at  the  Vienna  Hospital 
between  the  years  1842  and  1855,  regards  this  as  the  simplest  and  most 
efficacious  mode  of  treating  the  various  forms  of  syphilis.^ 

j\Iy  own  preference  for  inunction  is  very  strong,  and  I  resort  to  it  in 
most  of  the  old  cases  of  syphilis  which  come  under  my  care,  while  ad- 
ministering at  the  same  time  internally  large  doses  of  the  iodide  of  potas- 
sium. Some  of  the  most  gratifying  results  that  I  have  met  with  in  practice 
have  been  obtained  in  this  way,  as  I  shall  have  occasion  to  notice  hereafter. 

The  ciiief  objection  against  this  mode  of  treatment,  viz.,  the  staining  of 
the  linen  by  the  dark-colored  "  blue  ointment"  and  the  consequent  risk  of 
exposure,  has  been  obviated  by  the  introduction  of  the  oleates  of  mercury. 
The  latter,  which  are  liquid  up  to  the  ten  per  cent,  oleate  at  least,  may  be 
used  pure.  I  prefer,  however,  the  twenty  per  cent,  preparation  combined 
with  an  equal  weight  of  simple  cerate. 

I^.     Hjdrarg.  Oleinici, 

Cerati  Simpl.,  aa,  §j 30|00 

M. 

This  forms  a  consistent  mass,  of  a  light  fawn  color,  Avhich  is  free  from 
the  above-mentioned  objection.  The  oleates,  however,  are  more  apt  to 
irritate  the  skin  than  the  ung.  hyd.  They  should  therefore  be  used  with 
greater  caution  and  they  require  less  friction  in  their  application. 

In  making  the  applications,  it  is  better  to  avoid  the  more  delicate  por- 
tions of  the  skin,  and  also  those  portions  which  are  exposed  to  friction  or 
motion  or  are  usually  covered  with  hair.  For  the  sake  of  cleanliness,  the 
a[)plication  may  be  suspended  and  a  bath  of  hot  water  with  soap  be  taken 

'  Medical  Times  and  Gazette,  May  5,  1857  ;  from  tlie  Wien  Woclieiisclirift,  1856, 
No.  30.  Sigmund  lias  published  a  pamphlet  on  this  subject,  entitled  Die  Einrei- 
bungscur  bei  syphilisformen,  Wien,  1878. 


MERCURIALS.  799 

once  a  week.  For  the  sake  of  convenience,  I  usually  furnish  patients 
with  a  copy  of  the  following  directions : — 

Before  commencing  the  treatment,  take  a  hot  bath  and  cleanse  the  skin 
thoroughly  with  soap. 

The  evening,  before  retiring,  is  the  most  favorable  time  for  the  applica- 
tion, when  a  piece  of  the  ointment,  about  the  size  of  the  terminal  joint  of 
the  forefinger,  is  to  be  rubbed,  with  the  palm  of  the  hand,  into  some  portion 
of  the  surface  of  the  body  or  extremities  for  about  fifteen  minutes. 

At  each  application,  a  fresh  surface  should  be  selected,  so  as  to  avoid 
irritation  from  excessive  friction  of  any  one  portion. 

Any  of  the  ointment  which  remains  after  the  rubbing  should  be  left  upon 
the  skin  and  not  be  t\'ashed  off;  and  the  patient  should  wear  the  same 
flannel  or  merino  underclothes  constantly  night  and  day.  The  following 
order  may  be  followed  in  the  applications  : — 

1st  evening,  to  the  buttocks. 

2d        "  to  the  thighs,  but  not  near  the  groins  or  scrotum. 

3d        "         to  the  sides  of  the  chest,  but  not  in  the  armpits. 

4th       ''  to  the  internal  surfaces  of  ihe  arm  and  forearm. 

5th       "         to  the  back  or  belly.     The  former  application  is  best  made 

by  an  assistant,  whose  hand  is  protected  by  a  glove. 
6th       "  omit  the  application. 

7th     day,      take  a  bath  in  the  morning,  change  underclothes,  and  in 

the  evening  resume  the  applications  as  above. 

Keep  the  mouth  and  teeth  clean  by  the  use  of  a  brush  and  an  astrin- 
gent lotion,  and  the  bowels  open.  If  any  symptoms  of  salivation  occur, 
such  as  increased  flow  of  saliva,  tenderness  or  swelling  of  the  gums,  fetor 
of  the  breath,  etc.,  the  applications  should  be  suspended,  and  the  body 
cleansed  wMth  soap  and  water. 

If  tlie  oleate  of  mercury,  instead  of  the  mercurial  ointment,  be  employed, 
less  friction  is  required,  and  little  more  is  necessary  than  to  smear  the 
remedy  over  the  surface. 

When  only  a  mild  effect  from  mercury  is  desired,  the  extent  of  the 
application  may  be  limited.  Thus,  the  ointment  may  be  rubbed  into  the 
soles  of  the  feet  every  night,  or  some  of  it  may  be  spread  upon  pieces  of 
chamois  leather,  which  are  to  be  stitched  to  the  drawers  at  points  corre- 
sponding to  the  hams  and  the  calves  of  the  legs. 

Mercaricd  Suppositories 8u[)positories,  composed  of  about  a  drachm 

(4.00)  of  mercurial  ointment  and  a  sufficient  quantity  of  butter  of  cocoa, 
one  of  which  is  introduced  into  the  rectum  every  night,  have  been  tried 
in  the  treatment  of  syphilis,  with  unfavorable  results.  They  can  seldom 
be  borne  for  any  length  of  time,  on  account  of  the  tenesmus,  colic,  rectal 
catarrh,  and  fre([uent  desire  to  go  to  stool  wiiich  they  soon  occasion.  The 
syphilitic  lesions  appear  to  be  little  benefited  by  them,  and  they  often 
salivate. 

Hypodermic  Injection Tiie   hypoderniic   injection  of  preparations  of 

mercury  has  of  late  years  attracted  attention,  and  deserves  to  be  regarded 
as  a  valuable  addition  to  our  means  of  treatment  in  certain  cases.  Its 
general  adoption,  however,  as  a  means  of  treatment  is  not,  we  think,  to 


800  TREATMENT    OF    SYPHILIS. 

be  recommended,  since  the  injections  are  followed  by  considerable  pain 
lasting  often  for  several  hours,  and  there  is  always  a  possibility  of  causing 
troublesome  abscesses  at  the  points  of  insertion.  We  find  it  of  value  in 
those  cases  in  which  a  very  speedy  action  of  mercury  is  desired,  and  are 
in  the  habit  of  using  it  especially  in  cases  of  early  malignant  syphilis,  in 
Avhich,  within  a  few  months  after  infection,  the  patient  exhibits  deep 
ulcerations  of  the  fauces  or  ecthymatous  ulcers  scattered  more  or  less 
generally  over  the  integument.  In  such  instances,  we  know  of  no  better 
treatment  than  the  internal  administation  of  the  potassium  iodide  in  large 
doses,  combined  with  hypodermic  injections  of  corrosive  sublimate. 

The  preparation  of  mercury  recommended  by  Searenzio,  of  Pavia,  and 
first  used  for  this  purpose,  was  calomel,  of  which  about  three  grains  (0.20) 
were  rubbed  up  with  about  a  quarter  of  a  drachm  (l.OO)  of  glycerine  for 
each  injection,  which  was  repeated  at  intervals  of  a  week.  These  injec- 
tions were  found,  however,  very  frequently  to  produce  troublesome  ab- 
scesses, and  smaller  quantities  of  calomel,  from  a  grain  and  a  half  (0.09) 
to  a  grain  (0.06),  were  employed  at  shorter  intervals,  as  every  third  or 
fourth  day.  The  danger  of  abscesses  was  diminished  with  the  small  doses, 
but  was  not  entirely  removed,  so  that  injections  of  calomel  have  been  pretty 
much  abandoned. 

Subsequently,  Lewin,^  of  Berlin,  resorted  largely  to  injections  of  cor- 
rosive sublimate,  of  the  strength  of  four  grains  (0.25)  to  the  ounce  (30.00) 
of  distilled  water,  and  of  this  fifteen  minims  (1.00)  were  employed  at  each 
injection.  The  pain  following  the  injection  was  found  to  be  alleviated  by 
adding  one-tenth  to  one-eighth  of  a  grain  (O.OOG-0.008)  of  acetate  of 
morphia.  Lewin  made  his  injections  daily,  or  sometimes  even  twice  a  day, 
so  that  one-fourth  of  a  grain  (0.015)  of  the  sublimate  was  inserted  within 
twenty -four  hours,  and  he  stated  that  about  fifteen  injections  Avould  usually 
suffice  for  a  cure,  although  forty  to  fifty  w-ere  sometimes  required.  So  great 
frequency  appears  to  us  both  undesirable  and  dangerous  at  the  outset,  as 
we  have  found  salivation  produced  by  one  or  two  injections,  and  we  prefer, 
until  the  patient's  susceptibility  has  been  tested,  to  wait  some  two  or  three 
days  after  each  insertion  before  repeating  it,  meantime  watching  the  effect. 
Lewin  found  the  different  parts  of  the  body  equally  available,  so  far  as 
the  power  of  absorption  is  concerned;  but  it  is  important  to  select  a  poi'- 
tion  presenting  the  least  sensibility  in  the  integument,  and  the  least  ten- 
dency to  the  occurrence  of  inflammation  and  the  formation  of  abscesses, 
and  the  infrascapular  regions,  the  loins,  and  the  upper  i)ortions  of  the 
nates  possess  these  requisites  in  the  liighest  degree.  The  arms  had  better 
be  avoided.  There  is  reason,  how^ever,  to  believe  that  mercury  causes  the 
lesions  of  syphilis  to  disappear,  quite  as  much  by  its  direct  local  action 
ui)on  the  lesion  itself  as  by  any  alteration  in  the  constitution  of  the  blood 
wliich  it  effects.  Consequently  we  prefer,  if  jjossible,  to  make  the  injection 
in  the  neighborhood  of  the  lesion  we  hope  to  cin'e.  The  same  rules  as  to 
the  avoidance  of  veins,  injecting  only  into  the  derma,  wounding  the  hair 

'  Beliandlung  der  Syphilis  mit  sabcutaner  Sublimat-iiijectioii.     Berlin,  1869. 


MERCURIALS.  801 

bulbs,  etc.,  obtain  as  with  all  hypodermic  injections.  The  same  syringe 
should  never  be  used  on  syphilitic  and  non-syphilitic  subjects.  After  in- 
jecting corrosive  sublimate  the  point  of  the  syringe  should  be  carefully 
washed  and  dried,  and  sharpened,  if  necessary.  This  will  not,  however, 
entirely  prevent  its  being  corroded  by  the  sublimate,  and  points  used  for 
this  purpose  must  be  frequently  renewed.  The  pain  following  the  injection 
is  often  severe,  lasting  for  several  hours.  If  sufficient  care  be  used,  the 
recurrence  of  abscesses  will  not  be  frequent.  Salivation  should  be  carefully 
guarded  against. 

Our  experience  with  hypodermic  injections  in  the  treatment  of  syphilis 
has  been  chiefly  confined  to  solutions  of  corrosive  sublimate,  with  which 
w^e  have  had  every  reason  to  be  satisfied.  A  formula  which  we  have  used 
in  very  many  cases  is  the  following: — 

I^.     Hydrarg.  Chloridi  Corr.,  gr.  xl  .     .     .  2|60 

Glycerine,  5j 5  00 

Aqu«  Destill.,  gvj 24|00 

M. 

Twelve  drops  (0.80)  of  this  solution  contain  about  one-eighth  of  a  grain 
(0.008)  of  the  sublimate,  and  are  used  for  each  injection. 

Mr.  Stern'  has  recently  proposed  a  solution  of  the  double  chloride  of 
mercury  and  sodium,  which,  he  states,  will  not  produce  abscesses,  and 
causes  only  very  slight  stomatitis,  if  any.     His  formula  is  as  follows : — 


I^.     Hydrai'g.  Chloridi  Corr.,  gr.  iv  .     .     .  0 

Sodii  Chloridi  Puri,  Qij 2 

Aquffi  Destill.,  S^iij •'>5 

M. 


Half  a  drachm  (2.00)  of  this  mixture  is  daily  injected,  thus  giving  a 
dose  of  one-sixth  of  a  grain  (0.01)  of  the  sublimate. 

But  there  is  scarcely  any  end  to  the  other  solutions  of  mercury  which  have 
been  recommended,  chiefly  on  the  ground  that  they  were  less  likely  than 
corrosive  sublimate  to  produce  abscesses  or  occasion  stomatitis.  Having 
had  no  experience  with  most  of  them,  and  being  well  satisfied  witii  the 
mercuric  chloride,  we  shall  do  little  more  than  enumerate  some  of  them. 

The  substitute  for  corrosive  sublimate  which  has  attracted  most  atten- 
tion has  been  the  albuminate  of  mercury,  first  pro[)osed  by  Staub,"  of 
Strasburg,  in  1871,  and  afterwards  adopted  and  popularized  by  Prof.  H. 
von  Bamberger,  of  Vienna,  who  states  that  its  action  is  most  ra{)id;  that 
all  syphilitic  symptoms  disappear  after  ten  to  twenty  injections;  that  sup- 
puration and  infiltration  of  the  skin  are  avoided;  and  that  salivation  never 
occurs.  For  the  mode  of  prej)aring  this  solution,  which  is  somewhat  com- 
plicated, we  must  refer  to  the  original.^  We  had  several  bottles  put  up 
one  summer  by  the  eminent  chemist,  Dr.  Squibb,  of  Brooklyn,  but   the 

'  Progres  m^d.,  Paris,  dec.  21,  1878. 

2  Trait(!iiiont  do  la  syph.  par  los  injections  liypodcrmiques  do  sublime  a  I'etat 
de  solution  chloro-alhumineuse,  Paris,  1S72. 

»  Zcit.  d.  iiest.  Ap.  Ver.,  l.s7(J,  147,  177.     Also,  New  Remedies,  N.  Y  ,  1876,  p. 
167,  175. 
51 


802  TREATMENT    OP    SYPHILIS. 

fluid  became  so  soon   decomposed  that  we  were  unable  to  give  it  a  fair 
trial,  and  were  discouraged  from  testing  it  further.^ 

Dr.  Squibb  says  that  the  solution  is  pretty  accurately  as  follows : — 

Egg  albumen,  20  per  cent.  =  Dry  albumen,  2.5  per  cent. 
Mercuric  chloride,      1     "       "      =  1.0    "       " 

Sodium  chloride,         4    "       "      ^  4.0    "       " 

Distilled  Water,  75    "      "      =  92.5    "      " 

100  100 

The  amount  to  be  used  at  each  injection  is  a  cubic  centimetre,  or  about 
fifteen  minims,  which  contain  one-seventh  of  a  grain  (0.01)  of  the  mer- 
curic salt.  It  does  not  seem  to  be  a  true  definite  chemical  compound,  but 
merely  a  solution  of  the  very  irritant  chloride  of  mercury  in  a  saline  albu- 
minous fluid,  the  chloride  being  unchanged,  but  guarded  by  the  blandness 
of  the  solvent  vehicle. 

In  a  later  communication  we  learn  that  the  difficulty  of  preparing  a 
stable  and  clear  solution  of  the  albuminate,  has  led  Bamberger  to  re[)lace 
the  albumen  by  peptone.  Injections  of  tlie  albuminate  of  mercury  have 
been  favorably  reported  upon  by  Neumann  in  a  paper  before  the  Imperial 
Academy  of  Medicine,  of  Vienna,  and  by  Griinfeld.^ 

Daily  injections  of  seven  to  fifteen  drops  (0.50-1.00)  of  four  to  five 
grains  (0.22-0.30)  of  the  bicyanide  of  mercury  to  an  ounce  and  four 
scruples  (40.00)  of  distilled  water  were  employed  by  Sigmund,^  who  states 
that  within  a  period  of  ten  years  he  has  made  injections  upon  six  hundred 
and  thirty-one  persons,  and  has  met  with  only  five  cases  of  abscess.  He 
prefers,  however,  his  favorite  mode  of  treatment  by  inunction.  The  bi- 
cyanide has  also  been  used  by  Kroworzynski.* 

Gambarini,  of  Bologna,  employed  a  solution  of  the  biniodide  of  mercury, 
to  which  Ragazzoni^  added  a  little  iodide  of  potassium,  to  insure  the  com- 
plete dissolution  of  the  salt.     His  formula  was  this  : — 

03 


^..     Hydrarg.  Biniodidi,  gr.  ss       ....       0 
Potass.  lodidi,  q.  s. 
Aquje  Destill.,  3ss 2 

M. 


00 


Dr.  Weisfolg  uses  injections  of  the  nitrate  of  mercury  according  to  the 
following  formula : — 

R.     Hydrag.  Oxid.  Nit.  Crystall.,gr,  viij   .       050 

Aquae  Destill.,  gxiv SGJOO 

M. 

He  states  that  they  are  less  harmful  than  injections  of  the  mercury  per- 
chloride,  do  not  cause  abscesses,  and  supply  the  system  with  a  much  larger 

1  Prof.  Bamberger,  on  the  contrary,  states  that  this  solution  may  be  kept  in  a 
(German)  heated  room  all  winter  witlioiit  undergoing  change;. 

2  Wien.  Med.  Presse,  No.  38,  ISlii.  3  Wien.  Kiinik,  Oct.  1876. 

3  Vrtljschr.  f.  Dermat.,  Wien,  Heft  2,  187G. 

*  Gior.  ital.  d.  mal.  ven.,  Milano,  anno  viii,  1873,  p.  65.    Also  Lancet,  London, 
Nov.  1,  1873. 


EFFECTS    OF    MEKCURY.  803 

quantity  of  soluble  mercury  without  causing  salivation,  than  can  be  done 
in  any  other  way.' 

It  is  claimed  by  Lewin  that  the  results  of  the  hypodermic  injection  ot 
mercury  are  always  satisfactory,  except  in  cases  of  bone  or  brain  syphilis, 
and  that  relapses  are  less  frequent  than  after  the  internal  administration 
of  mercury  or  its  external  use  by  fumigation  or  inunction.  Sigmund,  on 
the  other  hand,  believes  that  the  field  for  its  employment  is  limited,  and 
that  it  is  adapted  only  for  the  milder  eruptions  of  the  secondary  stage. 
For  obvious  reasons,  it  is  not  to  be  employed  on  pregnant  women  nor  on 
young  children. 

Effects  of  Mercury. — Before  commencing  treatment  for  general 
syphilis,  a  patient  is  often  weighed  down  with  languor  and  general  malaise, 
which  are  the  effect  of  his  disease ;  under  the  use  of  mercury,  his  strength 
and  spirits  improve,  and  he  becomes  light,  active,  and  buoyant ;  mercury 
thus  far  has  indirectly  acted  as  a  tonic  ;  after  continuing  treatment  for 
some  time,  however,  it  is  frequently  the  case,  that  although  his  symptoms 
have  constantly  improved,  he  is  again  subject  to  depression,  but  if  ques- 
tioned as  to  the  cause  or  nature  of  his  feelings,  can  give  no  satisfactory 
reply ;  his  low  spirits  and  uncomfortable  sensations  cannot  be  defined  or 
explained,  but  are  none  the  less  real.  This  condition  is  unquestionably 
due  to  the  prolonged  influence  of  mercury,  since  it  yields  to  a  suspension 
of  specific  remedies,  whether  aided  or  not  by  a  cathartic,  and  a  change  of 
air  and  scene  for  a  few  days,  when  this  is  practicable.  These  conclusions 
from  clinical  experience  are  borne  out  by  analyses  of  the  blood  and  by 
actual  counting  of  the  red  corpuscles  in  a  given  quantity  of  the  blood  of 
healthy  men  and  animals,  while  under  the  influence  of  small  and  large,  or 
long-continued,  doses  of  mercury.  Liegeois''  was  the  first  to  announce 
tliat  small  doses  of  the  sublimate,  under  the  above  circumstances,  would 
cause  an  increase  of  weight,  while  large  doses  diminished  it.  In  1874^ 
Wilbouchewitch^  drew  the  conclusion  from  careful  experimentation,  that 
small  doses  of  mercury,  when  given  to  a  syphilitic  jmtient,  at  first  increase 
the  number  of  red  corpuscles,  and  slightly  diminish  the  numljcr  of  the 
white  globules. 

But,  for  further  light  on  this  subject,  we  are  indebted  to  a  very  valuable 
pa|)er*  by  Prof.  E.  L.  Keyes,  who,  by  means  of  tlie  hematiinetre,  made 
countings  of  the  number  of  red  corpuscles  of  the  blood  of  syphilitics  while 

'  Arch.  f.  path.  Anat.  etc.  (Virchow),  Bcrl.  B.  GG,  S.  3111,  and  Practitioner, 
Lond.,  Mcli.  1879,  p.  216. 

2  Dps  resultats  cliniqucs  et  scicntiruiucs  ohtenus  avcc  h'S  injections  sous-cuta- 
nees  de  sublime  5,  petites  doses  dans  retudo  de  la  syidiilis,  (Jaz.  d.  liop.,  I'aris,  88, 
p.  347;  89,  p.  350,  1869. 

3  De  I'influence  des  preparations  mercnrieUes  sur  la  richesse  du  sang  en  glo- 
bules-rouges  et  en  globules  blancs.  Arch,  de  physiol.  norm,  et  patli.,  Par.,  1874, 
p.  508. 

*  The  eflect  of  small  doses  of  mercury  in  modifying  the  number  of  the  red  blood- 
corpuscles  in  syphilis  ;  a  study  of  blood-counting  with  the  bfimatimetre.  Am. 
J.  M.  Sc,  Phila.,  Jan.  1876. 


804  TREATMENT    OF    SYTHILTS. 

taking  small  doses  of  niercurv,  and  who  arrived  at  the  following  conclu- 
sions : — 

1.  oMercury  decreases  the  number  of  the  red  cells  Avhen  given  in  excess, 
especially  in  hospitals  (Wilbouchewitch). 

2.  Syphilis  diminishes  the  number  of  red  corpuscles  below  the  healthy 
standard. 

3.  Mercury  in  small  doses  continued  for  a  short  or  for  a  long  period  in 
syphilis,  alone  or  with  the  iodide  of  potassium,  increases  the  number  of 
the  red  corpuscles  in  the  blood  and  maintains  a  high  standard  of  the  same. 

4.  Mercury  in  small  doses  acts  as  a  tonic  upon  healthy  animals,  increas- 
ing their  weight  (Liegeois).     In  larger  doses  it  is  debilitating  or  fatal. 

0.  Mercury  in  small  doses  is  a  tonic  (for  a  time  at  least)  to  individuals 
in  fair  health,  not  syphilitic.  In  such  individuals,  it  inci'eases  the  number 
of  the  red  corpuscles. 

In  whatever  way  mercury  is  introduced  into  the  system,  its  presence  in 
the  normal  secretions  and  excretions  of  the  body  may  be  demonstrated  by 
our  improved  modern  methods  of  analysis,  as  shown  by  Byasson,'  Betelli,^ 
and  Ludwig.^  The  bichloride  taken  by  the  mouth  has  been  recognized  in 
the  urine  two  hours,  and  in  the  salivation  four  hours  after  its  ingestion; 
still  later  it  is  found  in  the  sweat,  and  in  the  milk  of  nursing  women.  A 
considerable  portion  is  elimitated  by  the  bile,  and  is  found  in  the  stools, 
and  traces  of  it  may  be  discovered  in  the  various  tissues  for  a  considerable 
time  after  the  cessation  of  treatment. 

How  mercury  acts  in  the  cure  of  syphilis,  is  a  question  still  under  dis- 
cussion ;  whether  directly  upon  the  syphilitic  diathesis,  or  simply  as  an 
antiplastic  agent  U[)on  the  neoplasm  which  characterizes  the  lesions  of  this 
disease,  or,  in  other  words,  will  mercury  so  attenuate  and  even  extermi- 
nate the  syphilitic  influence  as  to  protect  the  patient  for  the  future — in 
fact,  cure  him,  or  does  it  simply  cause  the  disappearance  of  existing  lesions  ? 
In  our  opinion,  it  acts  in  both  these  ways.  No  one  can  question  its  influ- 
ence upon  the  lesions  themselves,  which  it  accomplishes  by  controlling  the 
hyperjemia  of  the  various  tissues  invaded,  and  by  causing  the  fatty  de- 
generation and  death  of  the  specific  cells  which  characterize  syphilitic 
manifestations.  But  we  go  further  than  this,  we  believe  it  capable  of 
removing  the  diathesis,  and,  in  fact,  of  curing  the  disease.  Without  this 
belief,  our  continuance  of  mercury  after  the  disappearance  of  the  lesions 
would  be  illogical,  and  the  advantages  of  such  continuance  are  demonstrated 
by  daily  observation. 

Many  practitioners  are  very  averse  to  the  use  of  mercury  with  patients 
who  show  any  tendency  to  pulmonary  disease.  We  believe  that  this  fear 
is  groundless,  provided  this  agent  be  used  in  the  small  doses  which  are  now 
emi)loyed,  at  the  same  time  that  the  proper  rules  of  hygiene  are  observed, 

t  Recherche  dii  mercure  dans  les  secretions  ;  J.  de  I'anat.  et  de  hi  physiol.,  Par. 
1872. 

2  Merc,  vinvenuto  nelle  urine  di  qiiattro  malati  sif.  ;  Gior.  ital.  d.  mal.  ven., 
Milano,  1876,  p.  149. 

3  SiGMUND,  Wien.  Klinik,  Oct.,  1876. 


EFFECTS    OF    MERCURY.  805 

and  that  tonics,  cod-liver  oil,  etc.,  adapted  to  the  lung-trouble,  be  not 
neglected.  Surely  no  sadder  cases  are  met  with  than  those  of  persons  who 
have  both  syphilis  and  tubercular  disease  to  contend  against.  Let  them 
be  relieved  of  the  former,  if,  as  we  believe,  it  can  be  done  with  safety. 

Salivation. — The  most  frequent  unpleasant  effect  of  the  administration 
of  mercurials,  and  the  one  which  it  is  especially  necessary  to  guard  against, 
is  salivation,  though  this  formerly  was  thought  to  be  a  desirable  result  of 
treatment  and  to  favor  the  cure  of  syphilis.  The  therapeutic  effect  of 
mercury  undoubtedly  precedes  its  morbid  action,  although  the  two  are 
often  separated  by  a  short  interval  only,  and  sometimes  appear  to  be  syn- 
chronous. If  we  carefully  observe  the  phenomena  which  ensue  after 
commencing  a  mercurial  course,  selecting  by  preference  a  case  which  has 
as  yet  received  no  treatment,  and  in  which  the  effects  of  mercury  are 
generally  most  clearly  marked,  they  are  usually  found  to  be  as  follows: 
for  the  first  few  days,  no  improvement  is  perceptible  in  the  sym)itoms, 
which  may  even  become  aggravated ;  the  chancre  may  spread  over  a  larger 
extent  of  surface,  or  new  secondary  lesions  may  appear ;  suddenly,  how- 
ever, the  primary  sore  begins  to  assume  a  more  healthy  aspect,  and  the 
process  of  cicatrization  to  advance  from  its  circumference  towards  the 
centre ;  the  indurated  base  and  neighboring  lymphatic  ganglia  lose  some- 
what of  their  hard  and  cartilaginous  feel ;  or  the  syphilitic  eruption  com- 
mences to  fade  away.  If  now  the  mercurial  be  continued,  even  though 
the  quantity  administered  be  not  increased,  tenderness  of  the  mouth 
appears  in  the  course  of  a  very  few  days,  sometimes  as  soon  as  the  second 
or  third  day  after  the  first  improvement  was  noticed  in  the  symptoms. 
In  a  few  instances  only  does  an  amelioration  in  the  symptoms  appear  to 
coincide  with  decided  salivation,  and  in  such  cases  the  action  of  the  mer- 
curial has  generally  been  so  itipid,  that  an  interval  between  the  two  may 
readily  have  been  overlooked.  Again,  if  mercury  be  continued  after 
salivation  has  taken  place,  its  therapeutic  action  is  not  increased,  but  in 
most  cases,  on  the  contrary,  the  symptoms  are  aggravated.  The  practical 
inference  from  the  above  remarks  is,  that  the  specific  treatment  of  syphilis 
may  be  carried  to  tenderness  of  the  gums,  if  we  wish  to  be  assured  tiiat 
its  full  therapeutic  effect  has  been  obtained,  but  that  it  should  not  inten- 
tionally be  pushed  to  complete  salivation,  and  never  in  any  case  be  con- 
tinued beyond  this  point.  A  patient  is  much  more  liable  to  be  salivated 
by  the  first  than  by  any  subsequent  course  of  mercury  ;  the  system  becom- 
ing tolerant  of  its  presence  by  repeated  use.  Patients  who  have  supposed 
themselves  extremely  sensitive  to  the  action  of  mercury,  founding  their 
opinion  upon  jwist  experience,  are  often  surpi'ised  at  the  large  amount 
which  they  are  able  to  take,  not  only  with  impunity,  but  witii  decided 
benefit  to  tlieir  symptoms  and  their  general  condition,  wiiile  under  treat- 
ment for  syphilis. 

Xlie  earliest  indication  of  the  morbid  action  of  mercury  upon  the  mouth, 
which  is  likely  to  attract  the  patient's  notice,  is  tenderness  of  the  gums ; 
this  is  soonest  felt  just  back  of  the  superior  incisor  teeth,  and,  in  the  lower 
jaw,  posterior  to  the   last  molars.     Patients  should  be  warned  of  these 


806  TREATMENT    OF    SYPHILIS. 

SA'mptonis  at  the  comniencement  of  iv  mercurial  course,  and  directed 
immediately  upon  their  ap[)earance  to  suspend  treatment.  Tiiis  precaution 
is  desirable,  though  it  sometimes  leads  timid  persons  to  imagine  the  mouth 
affected  long  before  this  result  has  actually  taken  place.  The  soreness 
attendant  upon  the  development  of  a  wisdom  tooth  is  often  mistaken  for 
mercurial  salivation,  and  various  other  causes,  as  decayed  teeth,  may  also 
produce  tenderness  of  the  gums,  and  a  fetid  breath.  It  is,  therefore, 
ahvays  desirable  for  the  surgeon  carefully  to  inspect  the  mouth  before 
commencing  treatment,  in  order  that  he  may  be  able  to  determine,  at  a 
subsequent  period,  how  far  to  attribute  its  unhealthy  condition  to  the 
influence  of  mercury. 

Other  prominent  symptoms  of  mercurial  stomatitis  are  a  metallic  taste 
in  the  mouth  ;  a  fetid  odor  of  the  breath — which,  however,  is  not  character- 
istic, since  it  may  be  perfectly  simulated  by  the  offensive  smell  proceeding 
from  a  want  of  cleanliness,  or  gums  diseased  from  other  causes ;  an  in- 
creased flow  of  saliva  ;  a  sensation  as  if  the  teeth  were  elongated,  and 
tenderness  when  they  are  struck  together ;  swelling  of  the  tongue,  which 
bears  the  impress  of  the  teeth  upon  its  sides;  tumefaction  of  the  mucous 
membrane  of  the  gums,  cheeks,  and  lips;  difficulty  in  talking  and  swallow- 
ino-;  enlargement  of  the  neijrhboring  ganglia;  sometimes  general  febrile 
disturbance  and  great  nervous  irritability ;  in  extreme  cases  ulceration  of 
the  soft  parts,  which  may  perforate  the  cheeks;  loosening  and  detachment 
of  the  teeth  ;  and  even  caries  of  the  alveoli  and  of  the  maxillary  bones. 

Under  the  cautious  method  of  administering  mercury  which  is  now 
adopted,  excessive  salivation  is  rarely  induced,  and  even  when  left  to  itself, 
usually  subsides  in  the  course  of  a  week  or  ten  days  after  the  suspension  of 
treatment.  Much,  however,  may  be  done  to  shorten  its  duration  and 
alleviate  the  sufferings  of  the  patient.  The  bowels,  if  confined,  should  be 
freely  purged,  and  the  action  of  the  skin  promoted  by  warm  baths  and 
underclothes  of  flannel.  The  most  distressing  symptoms  are  the  great 
difficulty  in  swallowing,  nervous  excitability,  and  inability  to  sleep. 
Nourishment  should,  therefore,  be  administered  in  a  liquid  and  concen- 
trated form,  as  strong  beef-tea;  and  rest  be  secured  by  the  exhibition  of 
Dover's  powder,  aided  by  a  hot  mustard  pediluvium  at  night,  which  will 
also  act  as  a  derivative  .from  the  head.  Half  an  ounce  or  an  ounce  of 
Labarraque's  solution  of  chlorinated  soda  in  half  a  pint  of  water  forms  an 
excellent  gargle  for  such  cases. 

Although  the  above  measures  should  by  no  means  be  neglected,  the 
most  direct  and  effectual  treatment  of  salivation  consists  in  the  administra- 
tion of  the  chlorate  of  potash.  We  usually  order  an  ounce  of  this  salt  in 
powder,  and  direct  the  patient  to  dissolve  from  one  to  two  teaspoonfuls  in 
a  pint  of  water,  milk  and  water,  flaxseed  tea,  decoction  of  marshmallow, 
or  in  whatever  other  vehicle  may  be  most  agreeable.  This  solution  is  to 
be  used  warm,  and  is  to  be  kept  constantly  within  reach  of  the  patient,  so 
that  he  may  frequently  rinse  his  moutli  with  it,  and  afterwards  swallow  a 
portion.     From  one  to  two  pints  are  sufficient  for  the  twenty-four  hours  ; 


EFFECTS    OF    MERCURY.  807 

and  about  half  of  tliis  quantity,  containing  one  or  two  drachms  (4.00-8.00) 
of  the  chlorate,  should  be  swallowed. 

It  cannot  be  doubted  that  the  amelioration  in  the  symptoms  which 
almost  always  takes  place  under  the  use  of  the  chlorate,  is  due  to  the 
remedy  and  not  to  the  mere  suspension  of  the  mercurial,  since  the  stomati- 
tis will  often  relapse  if  the  salt  be  too  soon  discontinued.  The  therapeutic 
action  of  the  chlorate  is  also  proved  beyond  question  by  Ricord's  experi- 
ments, which  show  that  the  stomatitis  will  subside  under  its  use  if  the 
mercurial  be  continued,  and,  in  many  cases,  even  if  the  dose  be  increased ; 
and  that  the  chlorate  may  be  employed  as  a  prophylactic  from  the  com- 
mencement of  treatment  in  persons  who  are  peculiarly  susceptible  to  the 
morbid  action  of  mercury,  without  interfering  with  the  remedial  effect 
upon  the  syphilitic  symptoms.^  This  statement  has  been  confirmed  by 
Laborde.^ 

During  the  use  of  raercuiy,  much  may  be  done  to  prevent  salivation  by 
attention  to  cleanliness  of  the  mouth,  and  by  avoiding  exposure  to  sudden 
changes  of  temperature  and  to  moisture.  The  teeth  should  be  brushed 
several  times  a  day,  or  the  mouth  be  rinsed  with  some  astringent  gargle, 
as  diluted  tincture  of  myrrh,  or  equal  parts  of  brandy  and  water  with  the 
addition  of  alum.  The  influence  of  cold  and  wet  must  not  be  regarded  as 
chimerical.  But  the  apprehension  which  is  often  entertained  by  patients 
in  regard  to  the  use  of  cold  drinks,  provided  other  hygienic  conditions  be 
favorable,  is  probably  groundless. 

The  young  surgeon  must  not,  however,  suppose  that  salivation  is  the 
only  indication  that  the  system  is  fully  under  the  influence  of  mercury. 
There  exists  a  class  of  patients  who,  it  would  seem,  cannot  be  salivated,  no 
matter  how  much  mercury  they  may  take;  but  in  such  persons  the  point 
of  saturation,  if  we  may  call  it,  is  indicated  in  other  ways,  commonly  by 
loss  of  appetite,  general  malaise  and  depression  of  spirits  ;  by  diarrhoea  ; 
or  by  ulceration  of  the  internal  surfaces  of  the  cheeks  on  a  line  correspond- 
ing with  the  free  edges  of  the  molar  teeth,  which  may  readily  be  mistaken 
for  a  syphilitic  ulcer.  With  due  care,  however,  any  serious  inconvenience 
from  these  symptoms  can  be  avoided  ;  only  let  it  be  remembered  that  any 
falling  off  in  the  general  condition  of  the  patient  during  a  mercurial  course, 
the  supervention  of  diarrhcea  wlien  the  remedy  was  for  a  time  well  borne, 
or  any  tendency  to  ulcerative  action  should  be  regarded  with  suspicion  and 
be  well  weighed  before  treatment  is  further  continued. 

Other  morbid  effects  of  mercui-y  are  an  eruption  upon  the  skin  (eczema 
mercuriale)  which  sometimes  follows  mercurial  inunction  ;  mercurial  trem- 
bling, and  other  affections  of  the  nervous  system  ;  mercurial  spanaemia  and 
cachexia,  etc. 

Mercurial  eczema  will  soon  disap})ear,  if  the  remains  of  the  ointment  be 
carefully  removed  by  warm  water  and  soap  and  the  part  be  dusted  with 
some  fine  powder  as  that  of  talc  or  precipitated  chalk.     The  other  morbid 

'  RtcoRD,  LoQons  sur  le  chancre,  p.  336. 
*  Laborde,  Gaz.  d.  h6p.,  24  avril,  1858. 


808  TREATMENT    OF    SYPHILIS. 

effects  of  mercury  are  so  infrequent  at  tlie  present  day  tliat  we  need  not 
discuss  them.  The  j)0|)nlar  idea,  fostered  unfortunately  by  some  physi- 
cians, that  mercury  remains  in  the  system  indefinitely  and  that  it  is  respon- 
sible for  tertiary  lesions,  as  gummata,  necrosis,  and  caries  of  the  bones,  etc., 
is  without  foundation.  These  lesions  appear  after  any  treatment  whatever, 
and  also  in  the  absence  of  all  previous  treatment,  thus  disproving  the 
assertion  that  they  are  caused  by  mercury. 

Duration  of  Treatment It  is  hardly  necessary  to  remark  that  treatment 

should  be  persevered  with  as  long  as  any  syphilitic  symptoms  remain. 
While  these  persist,  specific  remedies  must  be  continued  in  doses  graduated 
according  to  the  effect  produced  and  the  general  condition  of  the  patient,  in- 
creasing the  quantity  if  fresh  symptoms  appear  or  old  ones  cease  to  improve  ; 
diminishing  it,  or  suspending  treatment  altogether  for  a  time,  if  intestinal 
irritation,  salivation,  general  malaise,  or  decided  cachexia  supervene  ;  in 
all  cases  seeking  the  aid  of  hygienic  influences,  and  of  tonics.  The  effect 
upon  the  symptoms  is  to  be  taken  as  the  gauge  of  the  extent  to  wliich  mer- 
curial treatment  should  be  carried,  and  it  is  a  mistaken  notion  that  any- 
thing is  to  be  gained  by  causing  salivation  or  any  of  the  other  pathological 
effects  of  mercury.  So  soon  as  the  symptoms  begin  to  improve,  the  maxi- 
mum dose  required  for  the  time  being  has  been  reached  ;  and  this  dose 
should  be  continued,  subject,  however,  to  the  rules  just  mentioned,  until 
all  the  symptoms  have  disappeared,  and  for  several  months  afterwards. 
Persistence  of  the  induration  of  the  base  of  the  initial  lesion,  and  more 
frequently  that  of  the  neighboring  ganglia,  is  a  signal  of  danger  ahead, 
warning  us  not  to  stop  specific  medication.     As  Ricord  facetiously  says  : — 

"  Taut  que  le  dur  dure, 
Donnez  mercure." 

When  all  this  has  been  accomplished,  and  when  no  trace  of  the  disease 
remains,  the  question  comes  up  whether  treatment  should  be  still  further 
prolonged,  and  if  so,  for  what  period,  with  the  hope  of  securing  immunity 
for  the  future.  Upon  this  subject  the  greatest  variety  of  opinion  prevails 
among  different  authorities. 

Some  take  as  a  standard  the  period  which  has  already  been  occupied  in 
subduing  the  previous  symptoms,  and  would  have  the  treatment  still  con- 
tinued for  half  or  the  whole  of  the  same  length  of  time.  Others  are  con- 
tent with  a  month  or  six  weeks,  irrespective  of  the  previous  duration  of 
treatment;  while  many  practitioners  advise  a  period  of  from  six  months 
to  two  years.  There  is  an  equal  diversity  in  the  recommendations  as  to 
the  form  of  mercurial  to  be  employed,  the  mode  of  its  administration,  and 
the  extent  to  which  it  should  be  made  to  affect  the  system  ;  some  preferring 
the  bichloride  in  small  doses,  and  never  pushing  it  to  the  extent  of  touching 
the  gums  ;  and  others  constantly  keeping  their  patients  upon  the  verge  of 
salivation.  Again,  among  those  who  favor  a  prolonged  course  of  subse- 
quent treatment,  some  would  have  it  continuous,  while  others  advise  inter- 
missions from  time  to  time. 

Although,  in  a  previous  edition,  we  expressed  a  contrary  opinion,  further 


EFFECTS    OF    MERCURY,  809 

experience  leads  us  now  to  recommend  most  decidedly  that  treatment  should 
be  continued  for  at  least  two  years  or  two  years  and  a  half,  counting  from 
the  date  of  its  commencement,  and  this,  too,  even  in  such  cases  as  show 
no  sign  of  the  disease  after  its  first  general  outbreak.  Ricord^  was  in  the 
habit  of  advising  six  months  of  mercurial  treatment  in  as  full  doses  as  the 
system  would  bear,  followed  by  three  months  of  treatment  by  iodine,  but 
we  have  known  the  most  serious  symptoms  to  appear  within  a  month  or 
two  after  this  programme  had  been  faithfully  carried  out.  It  would  seem 
that  the  length  of  treatment  has  a  much  greater  influence  in  the  cure  of 
the  disease  than  the  amount  of  the  drugs  taken.  Thus,  a  certain  quantity 
of  mercury  pushed  to  the  verge  of  salivation  during  six  months  will  be 
much  less  advantageous  than  the  same  amount  given  in  smaller  doses  and 
distributed  over  several  years.  We  now  endeavor  to  impress  this  fact 
upon  our  patients  at  their  first  visit,  wiien  their  fears  are  greatest  and 
when  they  are  more  ready  to  listen  to  advice,  than  after  the  disappearance 
of  their  early  symptoms,  and  we  seek  to  convince  them  of  the  importance 
of  prolonged  treatment  if  they  would  protect  themselves  for  the  future. 

We  do  not  mean,  however,  to  imply  by  the  above  that  the  treatment 
should  be  continuous  during  the  period  stated,  as  recommended  by  some 
authors,  and  we  would  range  ourselves  on  the  side  taken  by  Hunt,'*  Four- 
nier,*  and  others,  in  favor  of  an  interrupted  and  not  a  continuous  course. 
The  tolerance  which  the  system  requires  in  the  continuous  use  of  any  drug, 
as,  for  instance,  opium  or  arsenic,  is  well  known,  and  the  same  is  true  of 
mercury.  If  this  metal  be  continued  month  after  month  without  inter- 
ruption, the  surgeon  will  often  find  new  lesions  cropping  out  at  a  time 
when  he  was  on  the  point  of  leaving  off  all  treatment;  whereas,  if  inter- 
missions be  allowed  from  time  to  time,  the  system  loses  its  tolerance  and 
the  remedy  acts  with  renewed  power  on  its  resumption.  The  length  of 
the  intermissions  is  subject  to  variations  in  ditferent  cases.  In  general, 
they  should  at  first  be  short,  and  not  exceed  one  or  two  weeks;  at  a  later 
period  they  may  extend  over  one  or  even  two  months,  during  which  time 
the  iodide  of  potassium,  either  alone  or  combined  with  tonics,  should  be 
given. 

The  question  will  naturally  be  asked,  What  indications  have  we  to  guide 
us  as  to  the  dose  after  the  more  manifest  lesions,  as  the  eruption,  etc.,  have, 
disappeared?  In  many  cases,  tiie  remaining  induration  of  the  base  of  the 
chancre  and  of  the  ganglia  may  be  relied  upon.  In  the  absence  of  this 
guide,  we  continue  the  mercurial  in  the  same  dose  as  has  thus  far  been 
used  for  about  two  months  after  the  eruption  upon  the  skin  and  mucous 
membranes  has  disappesired,  when  we  allow  a  respite  of  a  week  or  two. 
Upon  resuming  treatment,  the  dose  may  generally  be  reduced  one-third 
or  one-half,  but  no  absolute  rule  in  this  respect  can  be  laid  down,  since 

' 'lemons  sur  le  chancre,  2o  6fL,  Paris,  18(50,  p.  312. 

^  On  Syphilitic  Eruptions,  etc.,  with  espe<;ial  reference  to  the  Use  and  Abuse  of 
Mercury,  by  Thomas  Hunt,  F.R.C.S.,  2d  ed.,  London,  1854. 
3  I.e9ons  sur  la  syphilis,  Paris,  1873. 


810  TREATMENT    OF    SYPHILIS. 

each  case  must  be  decided  by  itself.  After  another  two  weeks'  treatment, 
a  longer  intermission  may  be  allowed,  as  for  a  period  of  four  weeks,  if  all 
has  been  going  on  well,  and  the  intermissions  may  gradually  be  increased 
in  length  at  a  later  date. 

After  a  course  of  treatment,  which  is  deemed  sufficient,  has  been  gone 
through  with,  the  patient,  on  his  last  visit,  is  sure  to  inquire  what  the 
probabilities  are  of  any  reappearance  of  the  disease,  and  if  he  can  regard 
himself  as  safe  for  the  futare.  Our  only  answer  can  be  that  there  is  no 
absolute  certainty  for  any  man  who  has  once  had  syphilis,  but  that  the 
chances  are  greatly  in  his  favor,  tliat  we  know  tliat  the  great  majority  of 
cases  (estimated  as  high  as  ninety-five  per  cent.)  which  have  been  thoroughly 
treated  are  absolutely  cured,  and  are  never  followed  by  a  relapse,  and  that 
he  has  great  reason  to  be  satisfied  with  this  prospect.  At  the  same  time 
he  should  be  warned  never  to  forget  the  fact  that  he  has  once  been  infected 
with  syphilis,  and  never  to  omit  to  state  this  fact  to  his  medical  attendant 
if  at  any  future  time  he  should  be  taken  ill.  The  confession  may  be 
entirely  unnecessary,  but  it  may  be  of  the  utmost  importance  in  the  diag- 
nosis and  treatment  of  his  illness.  Many  of  the  late  manifestations  of  this 
disease,  occurring  years  after  infection,  are  most  dangerous  in  their  char- 
acter, but  may  be  arrested  by  the  timely  use  of  the  proper  remedies.  In- 
deed, in  numerous  diseases,  and  especially  in  affections  of  the  brain,  it  is  a 
source  of  great  satisfaction  to  the  medical  attendant  to  be  able  to  point  to 
syphilis  as  the  cause,  since  the  course  of  treatment  is  then  evident,  and 
the  chances  of  the  patient's  recovery  are  most  decidedly  increased. 

Iodine  and  its  Compounds. — The  therapeutic  effect  of  iodine  and  its 
compounds  upon  syphilitic  symptoms  is  in  direct  ratio  to  the  duration  of 
the  disease.  Although  possessing  little  if  any  power  over  early  secondary 
manifestations,  their  action  upon  tertiary  lesions  and  those  of  the  transition 
stage  is  very  decided.  In  deep  tubercles  of  the  cellular  tissue,  rupia,  syphi- 
litic orchitis,  affections  of  the  bones  and  periosteum,  syphilitic  cachexia, 
etc.,  the  results  of  their  employment  are  frequently  almost  magical.  An 
unfortunate  patient  whose  life  has  been  rendered  miserable  for  months  by 
pains  in  his  bones  which  liave  deprived  him  of  sleep,  by  a  pustular  erup- 
tion upon  his  face  which  has  debarred  him  from  society,  by  deep  ulcera- 
tions about  the  pharynx  which  have  rendered  speech  and  deglutition 
almost  impossible,  and  which  finally  threaten  suffocation,  or  who  has  suf- 
fered from  any  other  of  the  numerous  late  manifestations  of  syphilis,  will 
in  most  cases  obtain  comjiarative  ease  and  comfort  in  the  course  of  a  few 
days  or  weeks  from  the  administration  of  the  iodides.  It  would  be  difficult 
to  name  the  circumstances  under  which  the  surgeon  feels  more  pride  in 
his  profession,  or  in  which  he  finds  more  conclusive  evidence  of  his  power 
over  disease,  than  when  he  is  able  to  recognize  the  symptoms  Avhich  indi- 
cate the  exhibition  of  these  remedies  and  can  watch  their  marvellous  effects 
from  day  to  day.  Unfortunately  the  iodides  possess  greater  power  to  sub- 
due tertiary  symptoms  for  a  time  than  to  cause  their  permanent  removal. 
The  disease  rapidly  declines  and  disappears  under  their  use,  but  in  most 


IODINE    AND    ITS    COMPOUNDS.  811 

cases  returns  in  a  few  weeks  or  months  after  their  suspension  ;  and  thus  the 
patient  becomes  the  shive  of  medicine,  or  is  obliged  to  resort  to  mercury 
for  an  effectual  cure. 

But  these  preparations  are  none  the  less  of  very  great  value.  Mercury 
alone  is  too  slow  in  its  action  to  meet  the  urgent  requirements  of  a  threat- 
ening perforation  of  the  soft  palate  and  like  dangerous  manifestations  of 
the  tertiary  stage.  By  the  use  of  the  iodides  the  patient  finds  almost  im- 
mediate, though  temporary  relief  from  suffering;  his  appetite  improves,  he 
gains  flesh  and  strength,  and  his  system  is  brought  into  a  proper  condition 
for  the  administration  of  remedies  which  will  prove  of  more  lasting 
benefit. 

The  ground  above  taken  with  regard  to  the  therapeutic  effect  of  iodine 
and  its  compounds  is  at  variance  with  that  assumed  by  some  most  eminent 
authorities,  and  especially  by  Ricord,  who  considers  the  iodide  of  potassium 
as  much  a  specific  for  tertiary  as  mercury  is  for  secondary  symptoms.  In 
our  own  practice,  however,  we  have  rarely  been  able  to  secure  permanent 
relief  for  our  patients  unless  the  former  agent  was  accompanied  or  followed 
by  the  latter,  and  this  experience  coincides  with  that  of  the  most  eminent 
authorities  of  the  present  day. 

Persons  are  frequently  met  with  who  have  taken  the  potassium  iodide 
for  years  and  years,  and  who  are  still  obliged  to  continue  it  if  they  would 
keep  their  symptoms  in  check.  They  generally  become  familiar  with  its 
use,  purchase  and  mix  it  for  themselves,  and  take  it  as  regularly  as  their 
daily  meals  even  in  doses  amounting  to  one  ounce  (30.00)  per  diem. 

The  observations  of  MM.  Melsens  and  Guillot  have  proved  that  iodide 
of  potassium  is  capable  of  rendering  soluble  mercury  or  any  of  its  com- 
pounds retained  within  the  tissues  of  the  body  and  of  causing  their  elimi- 
nation through  the  urinary  secretion,  in  which  they  may  be  detected  by 
chemical  analysis.  In  this  manner,  mercury  which  has  been  retained  in 
the  system  is  again  rendered  soluble,  and  before  elimination  may  exercise 
any  of  its  therapeutic  or  morbid  effects.  Thus  iodide  of  potassium  admin- 
istered subsequently  to  a  mercurial  course  has  fretiuently  been  known  to 
excite  profuse  salivation. 

The  question  has  been  raised  whether  iodide  of  potassium  by  itself  has 
any  power  over  syphilis,  and  whether  its  therapeutic  action  may  not 
be  entirely  explained  by  the  facts  above  stated.  According  to  this  view, 
it  is  only  curative  because  it  has  the  power  of  rendering  active  mercurial 
preparations  which  have  been  accumulated  in  the  system  by  previous  treat- 
ment ;  while  others  who  believe  that  t(;rtiary  syphilis  is  an  effect  of  mercury 
have  ascribed  the  action  of  iodide  of  potassium  to  the  elimination  of  this 
mineral  and  the  consequent  removal  of  the  supposed  cause  of  the  disease. 
Neitlier  of  these  suppositions  will  bear  the  test  of  examination.  Cases  of 
tertiary  syphilis  in  which  mercury  has  not  previously  been  given,  and  in 
which,  therefore,  the  independent  action  of  iodide  of  potassium  may  be 
tested,  are  not  common  ;  but  a  sufficient  number  liave  been  met  with  to 
prove  that  this  agent  does  not  play  so  secondary  and  insignificant  a  ])arta3 
has  been  attributed  to  it.     Of  lUo  cases  of  syphilis  successfully  treated 


812  TREATMENT    OF    SYPHILIS. 

Avitli  iodide  of  potassium  by  Ilassing  of  Copenhagen,  in  70  no  mercurial 
treatment  whatever  had  been  emphjyed.^  The  independent  action  of  the 
iodide  is  now  too  well  established  to  admit  of  a  question. 

The  solubility  of  iodide  of  potassium  enables  it  to  be  administered  in 
any  aqueous  or  alcoholic  mixture,  while  its  deliquescent  properties  poorly 
adapt  it  for  tlie  pilular  form.  It  may,  however,  be  obtained,  put  up  in 
sugar-coated  pills  or  in  compressed  tablets,  each  containing  either  three  or 
five  grains  (0.20-0.30),  but  these  should  always  be  dissolved  in  water  or 
other  fluid  before  swallowing. 

From  five  to  fifteen  grains  of  the  iodide  three  times  a  day  is  the  usual 
dose  with  which  to  commence  treatment  in  an  adult,  and  if  the  case  be 
properly  selected,  marked  improvement  will  generally  take  place  within  a 
week.  In  old  cases  of  syphilis,  however,  this  quantity  is  often  insufficient, 
and  it  may  be  necessary  to  increase  the  dose  to  one,  two,  or  even  six 
drachms  per  diem.  Symptoms  will  often  yield  to  fifty,  sixty,  or  one  or 
more  hundred  grains  a  day,  which  have  remained  stationary  under  a  less 
amount,  and  we  hold  that  the  following  rule  should  never  be  forgotten  : 
When  the  symptoms  appear  to  indicate  the  use  of  the  iodide,  the  case  should 
not  he  pronounced  intractable  to  this  remedy  unless  a  trial  has  been  made 
of  full  doses  and  these  have  been  found  to  be  without  effect. 

The  following  are  convenient  formula? : — 

I^.     Potassii  lodidi,  §ss 15 

Aquje  Cinnamomi,  ^ss 15 

M. 

Fifteen  drops  (1.00)  of  this  solution  measure  ten  minims  (O.Go)  and 
contain  seven  and  a  half  grains  (O.oO)  of  the  iodide. 

^.     Potassii  lodidi,  3ij 61 

Aqure,  §iv 120| 

M. 

Two  teaspoonfuls  (10.00)  three  times  a  day. 

The  action  of  the  iodide  of  potassium  is  supposed  to  be  increased  by 
combination  with  the  muriate  or  carbonate  of  ammonia. 

I^.     Potassii  lodidi, 

Amnionise  Muriatis,  aa  ^j     ,     .     .     .         4 
Tinct.  Cinchonse  Comp.,  §iv       .     .     .     120 
M. 
A  tablespoonful  (15.00)  tliree  times  a  day. 

5.     Ammoiii?e  Carbonatis,  5iss    ....         6 

Potassii  lodidi,  ,^iij 12 

Syrupi  Sarzae  Comj)., 

Aqufe,  aagiiss 80 

M. 
Dose. — One  drachm  (4.00)  three  or  four  times  a  day. 

Experience  shows  that  the  most  favorable  time  for  the  administration 
of  the  iodide  of  potassium  is  half  an  hour  or  an  hour  after  eating.  It  not 
unfrequently  excites  griping  pains  in  the  bowels,  which  may  be  avoided 

'  British  and  Foreign  Medical  Rev.,  Oct.,  1845,  p.  482. 


IODINE    AND    ITS    COMPOUNDS.  813 

by  the  addition  of  a  syrup  containing  tannic  acid,  as  the  syrup  of  cinchona 
or  of  orange  peel.^  The  addition  of  a  small  quantity  of  tannic  acid  to 
solutions  of  the  iodide  in  a  syrup  which  does  not  contain  tannin  answers 
the  same  purpose.  The  following  formula  is  employed  by  Ricord  and 
Nelaton  : — ^ 

I^.     Potassii  lodidi,  ^j 41 

Syriipi  Corticis  Aurantii,  §vj     .     .     .     200 
M. 

Dose.— A  tablespoonful  (15.00). 

Should  it  still  disagree  with  the  stomach,  relief  may  often  be  obtained 
by  drinking  one  or  two  gobletfuls  of  warm  water. 

The  iodide  of  sodium  and  the  iodide  of  ammonium  have  been  recom- 
mended as  substitutes  for  the  potassium  iodide.  They  are  less  agreeable 
to  the  taste  than  the  latter,  and,  we  think,  less  efficient,  but  they  serve  for 
a  change  and  are  better  borne  by  some  patients. 

The  iodide  of  iron  cannot  be  said  to  possess  any  special  anti-syphilitic 
power,  but  is  a  valuable  tonic  in  cachectic  or  chlorotic  subjects  either  with 
or  without  the  iodide  of  potassium.  We  often  employ  it,  especially  towards 
the  close  of  treatment  and  after  the  use  of  mercury.  Blancard's  pills  are 
the  most  convenient  form  of  administration,  or  the  liquor  ferri  iodidi  may 
be  used. 

The  contra-indications  to  the  use  of  iodide  of  potassium  'are  acute  or 
chronic  inflammation  of  the  digestive  organs,  plethora,  and  a  predisposi- 
tion to  hemorrhages.  Some  patients  cannot,  or  believe  they  cannot,  tole- 
rate it  even  in  the  smallest  doses.  These  are  difficult  cases  to  deal  with 
in  the  presence  of  a  tertiary  lesion.  Sometimes  the  evil  is  mei'ely  an 
imaginary  one  on  the  part  of  the  patient,  and  we  have  succeeded,  by  first 
administering  surreptitiously  small  doses  until  we  were  in  a  position  to 
convince  him  of  his  error,  in  carrying  the  remedy  up  to  the  usual  quantity 
given.  In  other  instances,  however,  the  smallest  dose  acts  as  a  poison, 
and  cannot  be  tolerated.  In  such  cases,  it  has  been  proposed  to  soak  the 
underclothes  in  a  solution  of  the  iodide  before  drying  them,  and  have  it 
absorbed  by  the  skin,  but  this  does  not  prevent  its  deleterious  influence. 
The  skin,  moreover,  is  only  capable  of  absorbing  it  after  imbibition  of  the 
epidermic  layers,  and  even  then  in  a  merely  infinitesimal  quantity.  A 
better  way  is  to  mix  it  with  vaseline  or  simple  cerate  and  api)ly  it  by 
inunction. 

Van  liuren  and  Keyes  state  that,  in  certain  cases  where  it  has  been 
impossible  to  administer  iodides  by  the  stomach,  they  iuive  obtained  favor- 
able results  by  injecting  daily  into  the  rectum  half-drachm  (2.00)  doses 
dissolved  in  an  ounce  or  more  of  beef-tea,  but  that  the  rectum  usually 
revolts  after  a  time,  especially  if  the  solution  of  tiie  iodide  be  too  concen- 
trated. 

'  BoixET,  Traitfi  d'iodntherapie,  Paris,  18.55,  p.  102,  and  L'Uniou  ni6d.,  1858,  p. 
487  ;  also  saiiii'  journal  for  March  6,  18(30. 
2  RiciiELOT,  L'Union  med.,  Feb,  28,  1860. 


814  TREATMENT    OF    SYPHILIS. 

In  obstinate  cases,  the  other  iodides  may  be  tried,  but,  in  intractable 
cases,  we  are  obliged  to  forego  the  use  of  this  remedy  and  resort  to  mer- 
cury alone,  preferably  by  inunction.  PLven  in  the  severest  forms  of  terti- 
ary syphilis,  as  serpiginous  ulcerations  of  the  skin,  gummata  of  the  palate, 
the  nasal  and  other  bones,  etc.,  in  which  the  usual  treatment  consists  of 
very  large  doses  of  the  iodide  of  potassium,  mercurial  inunctions  alone 
will  often  be  found  successful.^ 

Iodide  of  potassium  rarely  occasions  such  unpleasant  effects  as  to  de- 
mand more  than  a  mere  temporary  suspension  of  its  employment.  Its 
morbid  action  is  chiefly  manifest  upon  the  various  mucous  membranes. 
Some  patients,  shortly  after  commencing  its  use,  are  seized  with  coryza, 
M'hich  is  sometimes  quite  severe,  and  accompanied  with  acute  pain  in  the 
frontal  sinuses;  others  are  attacked  with  oedema  of  the  conjunctiva  oculi 
and  swelling  of  the  lids  ;  irritation  about  the  fauces  and  bronchitis  are 
occasionally  met  with,  and  redema  of  the  glottis  and  larynx.  Dr.  Fen- 
wick^  reports  a  most  remarkable  instance  of  this  kind,  occurring  after  only 
four  doses  of  ten  grains  each  had  been  taken,  and  in  which  the  life  of  the 
patient  Avas  saved  after  breathing  had  already  ceased,  by  tracheotomy. 

Gastro-intestinal  irritation  is  a  frequent  symptom  which  has  already 
been  adverted  to.  Loss  of  vision,  apparently  dependent  upon  sub-retinal 
effusion,  has  been  observed  in  a  few  rare  instances.  Salivation  sometimes 
occurs,  but  is  never  as  severe  as  that  occasioned  by  mercury,  nor  is  it  ever 
attended  by  ulceration  like  the  latter.  Strange  to  say,  many  of  these  un- 
pleasant effects  will  soon  cease  if  the  remedy  be  persisted  in,  the  system 
apparently  becoming  habituated  to  it.  It  has  been  falsely  asserted  that 
iodide  of  potassium  produces  atrophy  of  the  breasts  and  of  the  testicles. 

Ricord  states  that  he  has  accurately  measured  the  scrotal  organs  before 
and  after  treatment,  and  has  never  found  any  diminution  in  their  volume, 
unless  they  were  affected  with  syphilitic  orchitis,  which  generally  termi- 
nates in  atrophy.  Iodide  of  potassium  may  hasten  this  result,  when  it 
Avould  inevitably  have  taken  place  without  it,  but  cannot  produce  it  in 
healthy  organs.  In  general,  patients  taking  the  iodide  increase  in  weight. 
Zeissl  states  that  sleeplessness  is  produced  in  many  persons  by  the  iodide 
of  potassium. 

One  of  the  most  frequent  morbid  effects  of  this  remedy  consists  of 
various  eruptions  upon  the  integument,  generally  in  the  form  of  papules  or 
acne-pustules,  and  often  of  furuncles  or  boils.  They  are  quite  common 
about  the  neck  and  face,  where  they  present  an  unsightly  appearance  and 
are  the  source  of  much  annoyance  to  patients  who  frequent  society,  and 
also  upon  the  trunk  and  upper  extremities. 

Adamkiewicz,^  in  a  very  severe  case  of  acne  produced  by  the  adminis- 
tration of  iodine,  was  able  to  demonstrate  the  presence  of  iodine  in  the  pus 
of  the  acne-pustules.     The  latter  are  sinqdy  inflamed  sebaceous  glands, 

'  Consiilt  SifiMUNi),  Neuero  BeLandluiigsweisen  der  Syphilis,  Wien,  1876,  S.  27. 

2  Lancet,  Loud.,  Nov.  13,  1875. 

*  Charite-Aiin.,  Berl.,  iii,  1878,  p.  381. 


IODINE    AND    ITS    COMPOUNDS.  815 

and  he  therefore  infers  that  they  act  as  true  excretory  organs  and  elimi- 
nate the  iodine.  This  disagreeable  effect  of  the  iodine  may  be  altogether 
prevented  or  greatly  alleviated  by  adding  to  each  dose  of  the  remedy  from 
five  to  ten  minims  (0.32-0. Go)  of  the  liquor  potasste  arsenitis  (Fowled). 

An  erythematous  and  an  eczematoiis  eruption  have  also  been  noticed  to 
be  produced  by  the  com[)Ounds  of  iodine.' 

In  the  erythematous  form,  the  skin,  and  especially  that  covering  the 
forearm,  assumes  an  intense  red  color,  which  is  sometimes  isolated  in  points, 
and  at  other  times  covers  the  whole  surface  ;  the  temperature  of  the  part 
is  also  heightened.  This  erythema  disappears  if  the  treatment  be  sus- 
pended, or,  if  the  latter  be  continued,  runs  into  a  papular  form. 

The  eczematoiis  variety,  which  closely  resembles  ordinary  eczema,  is 
very  rare.  It  most  frequently  affects  the  hairy  scalp  and  the  neighbor- 
hood of  the  scrotum,  and  soon  disappears  on  stopping  the  iodide.  M. 
jMercier^  describes  a  case  in  which  moderate  doses  of  iodide  of  potassium, 
upon  two  occasions  in  the  same  person,  brought  out  an  eruption  of  eczema 
rubrum  over  the  whole  body,  attended  by  severe  fever  and  dyspnoea,  and  so 
cojjious  an  exudation  of  fluid  that  the  bed  on  which  the  patient  lay  was 
completely  wet  through. 

In  1871,  the  writer  published  what  he  supposed  to  be  the  first  case  on 
record  of  a  bullous  eruption  produced  by  iodide  of  potassium.^  The  erup- 
tion appeared  suddenly,  after  taking  only  three  doses  of  the  iodide  of 
twenty  grains  each,  and  occupied  the  back  of  the  neck,  forehead,  face,  and 
backs  of  the  hands — in  other  words,  those  parts  which  were  most  exposed 
to  the  air.  Within  thirty-six  hours  after  taking  the  first  dose,  the 
bullas  were  very  large,  some  of  them  one  and  a  half  inches  in  diameter. 
Some  were  filled  with  a  clear  serum  ;  others  were  turbid  or  of  a  reddish  or 
purplish  color.  The  surrounding  skin  was  reddened  and  cedematous.  The 
patient  complained  of  heat  and  a  burning  sensation  in  the  parts.  It  was 
ascertained  that  on  three  previous  occasions  he  had  been  affected  in  the 
same  way  upon  taking  the  iodide.  To  Dr.  John  O'Keilly,  of  New  York, 
is,  however,  due  the  precedence  of  recognizing  the  dependence  of  bulke 
upon  tlie  potassium  iodide.* 

This  eruption  has  in  later  years  been  studied  by  a  number  of  dermatolo- 
gists, and  especially  by  Hutchinson*  and  Tilbury  Fox,*  under  the  name  of 
Ilydroa.  In  rare  instances  it  occurs  over  the  whole  body  and  is  always 
symmetrical.     In  its  earliest  stage,  the  bullae  are  quite  small,  not  larger 

'  These  eruptions  have  been  carefully  studied  hy  Dr.  H.  E.  Fischer,  of  Vienna, 
Union  med.  Par.,  31  Jan.,  18G0,  from  Wien.  med.  Wclmschr. 

2  Observations  nouvellcs  sur  le  traitenient  des  valvules  du  col  de  la  vessie,  Paris, 
1847,  and  Union  m6d.  Par.,  11  fev.,  1860. 

'  Pemphigus  produced  by  the  administration  of  Iodide  of  Potassium,  by  F.  J. 
Bumstead,  M.D.,  Am.  J.  M.  So,,  Pliila.,  July,  1871,  p.  99. 

*J^.  Y.  M.  Gaz.,  Jan.,  1854. 

5  The  causes  of  some  of  the  eruptions  which  have  been  classed  as  Hydroa; 
Clinical  Soc.  Trans.  Lond.,  vol.  viii,  1875,  p.  151. 

•>  Trans.  Clinical  Soc.  of  London,  1878. 


816  TREATMENT    OF    SYPHILIS. 

than  a,  shot,  and  closely  resemble  those  of  smallpox,  but  their  rapid 
development  into  vesications  of  larger  size  and  without  umbilical  depres- 
sion soon  settles  the  differential  diagnosis.  The  eruption  dries  up  and 
disappears  in  a  few  days  if  the  iodide  be  stopped.  The  microscopical  ap- 
pearances of  the  skin  in  this  affection  have  been  studied  by  Dr.  Geo.  Thin.^ 

Purpura  is  another  cutaneous  effect  of  the  iodide  of  potassium  and  is 
sometimes  of  a  very  serious  character.  It  does  not  appear  to  be  dependent 
upon  tlie  patient's  general  condition  nor  upon  the  severity  of  his  syphilitic 
lesions,  but  upon  his  individual  idiosyncrasy.  It  usually  appears  within  a 
short  time  after  commencing  the  iodide,  perhaps  after  taking  only  a  very 
few  doses.  In  most  cases  it  completes  its  course  in  a  few  days,  even  if 
the  medicine  be  continued,  but  is  liable  to  recur  if  the  dose  be  increased. 
The  discoloration  of  the  skin  may  be  seen  for  several  weeks. 

The  parts  most  liable  to  be  affected  are  the  legs  below  the  knees  and  the 
neck  and  face,  though  other  portions  of  the  integument  may  be  attacked. 
The  purpuric  spots,  which  cannot  be  effaced  by  pressure  with  the  finger, 
are  sometimes  small  and  seated  around  the  hair  follicles.  Fournier*' 
describes  a  miliary  form,  consisting  of  small,  non-[)ruriginous,  sanguineous 
spots,  of  which  he  has  met  with  fifteen  instances,  all  of  them  except  one 
confined  to  the  legs.  In  other  cases  the  spots  attain  the  large  size  of 
ordinary  purpura  htemorrhagica,  and  maybe  an  inch  or  an  inch  and  a  half 
in  diameter.  Mackenzie'^  reports  a  case  of  death  in  a  syphilitic  infant, 
aged  five  months,  following  the  administration  of  two  grains  and  a  half  of 
the  iodide  of  potassium.  In  this  case,  the  Avhole  of  the  face,  eyelids,  and 
lips  became  swollen  and  of  a  purplish-black  hue  ;  there  were  a  few  hemor- 
rhagic spots  on  the  arm  ;  none  elsewhere. 

Mr.  Langston  Parker  described  a  hard,  tubercular  condition  of  the 
tongue,  which  is  sometimes  cracked  and  fissured,  consequent  upon  the 
long-continued  use  of  iodine.*  This  affection,  which  we  have  never  seen, 
is  said  to  closely  resemble  syphilitic  tubercles,  from  which  it  may  be  dis- 
tinguished by  its  disappearance  soon  after  the  discontinuance  of  the  iodine. 

In  addition  to  the  morbid  effects  already  mentioned,  iodide  of  potassium 
in  large  doses  sometimes  gives  rise  to  a  combination  of  symptoms  known 
under  the  name  of  "  iodism,"  and  consisting  of  a  sensation  of  oppression  in 
the  head,  tinnitus  aurium,  neuralgia,  spasmodic  action  of  the  muscles, 
impaired  voluntary  motion,  and  sluggishness  of  the  intellect. 

Iodoform The  internal  administration  of  iodoform  as  a  substitute  for 

the  potassium  iodide  is  favorably  mentioned  by  some  authorities.  Berkeley 
HilP  has  given  it  in  pills  of  one  and  a  half  grains  (0.09)  with  the  extract 
of  gentian,  commencing  with  three  pills  a  day  and  increasing  to  eiglit  or 

'  Lancet,  London,  Nov.  16,  1878. 

2  Rev.  mens,  de  med.  et  de  chir.,  Paris,  sept.,  1877  ;  also  Med.  Times  and  Gaz., 
Lond.,  Oct.,  1877,  p.  445. 

3  Med.  Times  and  Gaz.,  Lond.,  Feb.,  1879. 

*  Prov.  M.  and  S.  J.,  Lond.,  No,  3,  1852 ;  also  Parker  on  Syphilitic  Dis.,  p.  211. 
5  Brit.  M.  J.,  Lond.,  Jan.  26,  1878. 


VEGETABLE    DECOCTIONS    AND    INEUSIONS.  817 

ten,  and  with,  lie  thinks,  good  effect.  Our  own  experience  in  a  number  of 
cases  has  been  against  it.  It  has  had  little,  if  any  influence  upon  the  sy- 
philitic lesions  ;  its  odor  rising  from  the  stomach  and  passing  from  the 
bowels  in  the  flatus  renders  the  patient  disgusting  to  himself  and  his 
friends  ;  and,  if  long-continued  or  given  in  considerable  doses,  it  produces 
intestinal  catarrh  and  even  iodisni. 

Nitric  Acid  and  Gold Nitric  acid^  was  formerly  recommended  by 

Alyon  and  others,  for  the  treatment  of  syphilis,  and  is  still  a  favorite  remedy 
Avith  the  "  homoeopaths,"  whose  leader,  Hahnemann,  in  1825  also  revived 
the  use  of  gold,  which  is  said  to  have  been  employed  by  the  Arabians  in 
the  treatment  of  venereal  diseases,  and  which  was  recommended  by  Chre- 
tien, of  Paris,  in  1811.  According  to  the  "  homoeopaths,"  gold  is  of  great 
value  in  many  tertiary  lesions,  especially  sarcocele,  affections  of  the  bones, 
and  syphilitic  cachexia.^  Our  experience  with  these  agents  has  been 
limited,  but  has  led  us  to  assign  to  them  but  little  value. 

Vegetable  Decoctions  and  Infusions. — Decoctions  and  infusions 
of  sarsaparilla,  saponaria,  water-dock,  stillingia,  and  other  vegetable  sub- 
stances have  at  times  enjoyed  considerable  reputation  with  the  profession 
for  the  cure  of  syphilis,  and  are  still  held  in  high  repute  by  the  public. 
When  used  alone  they  are  found  to  be  entirely  destitute  of  anti-syphilitic 
properties,  and  when  given  in  combination  with  mercurials  and  iodide  of 
potassium,  do  not  appear  to  add  to  the  effect  of  the  latter.  This  statement 
coincides  with  the  opinion  of  most  surgeons^  who  have  had  the  largest  ex- 
perience in  their  use,  and  has  been  confirmed,  so  far  as  regards  sarsaparilla, 
the  reputation  of  which  has  exceeded  that  of  all  the  others,  by  a  series  of 
careful  experiments  conducted  by  Sigmund,  of  Vienna,  who  concludes 
that  this  substance  does  not  exercise  the  slightest  perceptible  influence  on 
the  course  or  termination  of  syphilitic  diseases.*  Whatever  virtues  are 
possessed  by  these  substances  can  only  be  ascribed  to  their  influence  as 
tonics,  stomachics,  diuretics,  or  diaphoretics,  to  which  the  ordinary  mode 
of  their  administration  in  a  large  amount  of  fluid  greatly  contributes. 
When  employed  with  these  purposes  in  view  they  may  prove  useful  ad- 
juvants of  mercury  and  iodide  of  potassium,  but  alone  are  unworthy  of 
confidence. 

Clifford  Allbutt,^  however,  believes  that  the  inefiicacy  of  sarsaparilla  is 
due  to  the  small  doses  in  which  it  is  given,  and  recommends  from  a  pint 
to  a  pint  and  a  half  of  the  decoction  to  be  taken. 

»  See  an  cUrticle  by  Dr.  Riidd  on  the  "  Influence  of  a  Long  Course  of  Nitric  Acid 
in  Reducing  tlie  Enlargement  of  the  Liver  and  Spleen  that  somethoes  i-esults 
from  the  Syijhilitic  Cachexy." — Sydenham  Soc.'s  Year  Book,  18G3,  from  the  Brit. 
Mi'A.  Journ. 

2  HuauES,  Manual  of  Pharmacodynamics,  3d  ed.,  p.  154. 

3  See  Stille's  Materia  Medica,  ii,  p.  948. 

•»  British  and  For.  Mcd.-Chir.  Rev.,  Am.  ed.,  July,  18G0,  p.  183. 
5  Practitioner,  Lond.,  May,  1870. 
52 


818  TREATMENT    OF    SYPHILIS. 

Zittmaii's  decoction,  a  favorite  remedy  with  the  Germans,  contains  an 
appreciable  amount  of  mercmy,  but  acts  cliiefly  as  a  catliartic  and  diapho- 
retic. The  large  doses  in  -which  it  has  been  recommended,  a  pint  of  the 
stronger  preparation  in  tlie  morning,  and  a  quart  of  the  weaker  at  night, 
can  rarely  be  borne  without  producing  violent  purging.  We  have  em- 
j)loyed  it  with  good  results  in  some  inveterate  cases  of  syphilis,  giving  from 
eight  ounces  to  a  pint  of  the  strong  preparation  in  the  course  of  the  day, 
and  aiming  to  produce  from  three  to  five  discharges  from  the  bowels.  In 
some  instances  it  has  had  a  very  marked  eifect  in  increasing  the  appetite 
and  improving  the  general  condition  of  the  patient. 

Tayuya Within  the  last  few  years,  a  new  remedy  has  been  proposed 

for  the  treatment  of  syphilis  and  of  scrofula,  viz.,  the  tincture  of  the  root 
of  Tayuya.  The  botanical  name  of  this  plant,  indigenous  to  South  America, 
is  Dermophylla  pendulina,  or,  according  to  Bentham  and  Hooker,^  it  does 
not  appear  to  differ  from  Trianosperma,  one  of  the  cucurhitacece,  but  it  is 
not  entirely  known. 

The  tincture  is  given  at  first  in  doses  of  from  fifteen  to  twenty  drops, 
diluted  with  water,  and  it  has  also  been  injected  hypodermically.^  It  seems 
to  have  excited  some  little  interest  in  Italy,  but  the  reported  cases  in  which 
it  has  been  tried,  are  not  conclusive  as  to  its  value.  It  is  said  to  have  acted 
well  in  three  cases,  occurring  in  the  wards  of  Prof.  Gamberini,  of  Bologna 
(Galassi).  Prof.  Pellizzari,  of  Florence,  and  other  recent  writers,  state  that 
it  has  completely  failed  in  their  hands.''  Dr.  J.  Nevins  Hyde,  of  Chi- 
cago, imported  a  number  of  bottles  of  this  article,  which  he  tried  in  his 
own  practice  and  distributed  to  some  friends  for  trial.  They  failed  to  find 
in  it  any  anti-syphilitic  power  (oral  com.). 

Tayuya  is  a  proprietary  medicine  of  the  Messrs.  Ubicini  Bros.,  of  Pavia, 
who  carefully  conceal  its  origin.  So  far  as  present  appearances  go,  it  is 
likely  to  share  the  fate  of  the  many  nostrums  that  have  preceded  it.  A 
partial  bibliography  upon  the  subject  is  appended." 

Balneotiierapia At  the  time  when,  under  the  teachings  of  Priess- 

nitz,  Jiydropathy  was  believed  to  cure  all  diseases,  syphilis  was  included 

'  Grenera  plantariim,  vol.  i,  p.  835,  Lond.,  18G7. 

2  Gazz.  med.  ital.  lomb.,  Sept.  1878. 

3  Faraoni,  Tayuya,  Relazione  al  Congref3so  medico  di  Torhio,  18  Scttembre,  187C. 
Galassi,  Gior.  ital.  d.  mal.  ven.,  Milaiio,  Nov.  25,  1S7(J. 

LoxGHi,  Gazz.  med.  ital.  feder.  lomb.,  Milano,  Nov.  25, 1876. 
Bettelli,  Principii  attivi  del  Tayuya,  Bologna,  1877. 
Tanturri,  Morgagni,  Napoli,  Oct.  8,  1877. 
Faraoni,  Seconda  relazione,  Milano,  1878. 
Castiglioni,  Ann.  di  med.  pubb.,  Roma,  Aug.  15,  1873. 
Veladini,  Gazz.  med.  ital.  lomb.,  Milano,  .Inly  C,  1878. 
Torregkosso,  same  journal,  July  6,  1878. 

LoNGHi,  same  journal,  Dec.  21,  1878  ;  .Jan.  4,  1879  ;  .Jan.  11,  1870,  and  Jan.  18 
1879. 
RoNUS,  Cor.  Bl.  f.  schweiz.  Aerzte,  Basel,  Sept.  15,  1878. 
Geber,  Vrtljschr.  f.  Dermat,  1879,  p.  285. 


BALNEOTIIERAPIA.  819 

in  the  category.  It  is  now  known  that  the  use  of  baths,  and  even  the 
systematic  "water-cure,"  has  no  direct  influence  upon  this  disease,  and 
this  fact  is  frankly  acknowledged  by  raany  of  the  best  known  medical  men 
in  charge  of  bathing  establishments  in  Europe.^  All  that  is  claimed  for 
this  course  of  treatment  is,  that  it  is  especially  adapted  to  patients  suffering 
not  only  from  syphilis,  but  also  from  the  (supposed)  excessive  or  injudi- 
cious use  of  mercury;  and,  again,  Hofmeister^  thinks  that,  during  the 
cold-water  treatment,  aliments  and  medicines  are  more  completely  digested 
and  assimilated,  and  that  by  this  means  favorable  results  are  produced  by 
means  of  a  reduced  quantity  of  medicine.  Less  mercury  may,  therefore, 
be  employed,  and  if  a  cumulative  effect  is  produced,  it  is  readily  cast  off 
in  consequence  of  the  increased  excretion  and  secretion.  Furthermore, 
tjie  regimen  to  which  patients  are  subjected  in  the  cold-water  treatment 
materially  facilitates  metamorphosis.  There  is  reason  to  believe  that  the 
fre(iuent  use  of  baths  hastens  the  appearance  of  secondary  lesions. 

In  America,  the  Hot  Springs  of  Arkansas  have  acquired  great  notoi'iety 
in  the  treatment  of  syphilis,  and  thousands  upon  thousands  flock  to  them 
every  year.  It  is  not  claimed  that  the  water  of  these  springs  has  any 
virtue  discoverable  by  chemical  analysis,  but  the  foolish  pretense  has  been 
set  forth  that,  owing  to  the  fact  that  it  is  heated  in  the  bowels  of  the 
earth,  it  possesses  an  occult  power  far  surpassing  water  heated  in  a  tea- 
kettle over  the  fire,  or  in  the  boiler  of  a  kitchen  range.  It  is  a  notorious 
fact,  however,  that  the  water  is  not  relied  upon  to  effect  a  cure,  but  that 
mercury,  generally  by  inunction,  and  the  iodide  of  potassium  are  employed 
by  the  resident  physicians  in  doses  carried  to  the  utmost  extreme.  Under 
this  energetic  but  spasmodic  treatment,  the  existing  lesions  disa])pear 
for  a  time,  only  to  return  again,  as  Ave  have  frequent  occasion  to  observe 
soon  after  the  patient's  return  home.  We  cannot  believe  that  even  this 
temporary  benefit  is  due  to  the  water,  but  we  ascribe  it  to  the  change  of  air 
and  scene,  to  the  relaxation  from  business  cares,  and,  above  all,  to  the 
specific  remedies  employed.  For  the  sake  of  the  first  two  of  these  three 
desiderata,  tlie  rich  patient  may  be  counselled  to  visit  the  Hot  Springs, 
but  the  man  of  moderate  means,  who  would  sacrifice  his  all  by  going,  had 
better  be  told  that  he  can  do  as  well  at  home  under  proper  treatment. 

Sulphur  springs  have  also  acquired  considerable  reputation,  especially 
in  Europe,  not  so  much  as  a  curative  agent  in  syphilis,  as  a  means  of 
bringing  to  the  surface  any  latent  remains  of  the  diathesis;  and  patients 
are  told  that  if,  after  taking  the  baths  and  drinking  the  water  for  a  certain 
number  of  weeks,  no  new  lesions  appear,  they  may  regard  themselves  as 
cured.  Whether  this  is  true  or  not,  is  a  difficidt  jioint  to  decide,  since  the 
natural  course  of  syphilis  is  to  api)ear  in  successive  outbreaks,  and  whether 
these  are  hastened  any  more  by  sid|)liur  water  than  by  any  other  water 
we   are   unable  to  say.     Sul[)lun*   baths  are   also   extolled  as  a  means  of 

'   Our  space*  will  not  allow  us  to  give  their  oviilence  in  detail,  but  it  may  Im 
found  in  Zoissl's  admirable  work,  vol.  ii,  p.  40)3. 
2  Med.-Chir.  lluudschau,  Wien,  Dec.  187(i. 


820  TREATMENT    OF    SYPHILIS. 

removing  mercury  from  the  system,  and  one  ])Ound  of  this  metal  is  said 
to  have  been  extracted  from  the  body  of  an  unfortunate  patient  under  the 
care  of  a  physician  of  Prague,  by  means  of  u  single  bath!  Credat  Judceus 
Apella,  non  eyo. 

CLi:\rATic  Influences — A  warm  climate  is  more  favorable  than  a 
cold  one  for  persons  under  treatment  for  syphilis.  In  voyages  round  the 
■world  made  by  vessels  penetrating  the  different  zones,  it  has  been  noticed 
tliat  the  sailors  affected  with  this  disease  did  better  in  the  warm  than  in 
the  cold  regions,  and  this  is  what  might  reasonably  have  been  expected. 
A  refuge  to  a  warmer  climate  from  the  severity  of  our  northern  winters 
might,  therefore,  be  recommended  to  many  patients,  were  it  only  possible 
to  secure  for  them  constant  supervision  under  the  care  of  some  one  com- 
petent physician,  and  avoid  their  being  left  to  themselves  or  seeking 
advice  from  a  dozen  different  sources  in  their  travels. 

"  Sypiiilization." — About  the  year  1844,  before  the  distinct  nature  of 
the  chancroid  and  syphilis  was  known,  M.  Auzias  (Turenne)  undertook  u 
series  of  experiments  to  test  the  accuracy  of  the  doctrine  advanced  by 
Hunter  and  Ricord,  that  syphilis  is  not  communicable  to  the  lower  animals. 
By  protecting  the  inoculated  points  in  such  a  manner  that  the  animal  could 
not  lick  them  and  thus  remove  the  virus,  he  was  able  to  produce  local 
ulcers  with  a  soft  base  upon  monkeys,  cats,  rabbits,  and  horses ;  but 
neither  in  his  experiments  nor  in  those  of  others  who  followed  him,  were 
general  symptoms  ever  developed,  showing  that  the  system  was  not  con- 
taminated with  the  syphilitic  virus  and  confirming  the  statement  of  Hunter 
and  Ricord.  Moreover,  there  is  reason  to  believe  that  the  virus  employed 
in  many,  at  least,  of  these  inoculations  was  chancroidal  and  not  syphi- 
litic, since  matter  was  taken  from  the  sores  developed  upon  the  animals 
and  inoculated  on  four  occasions  upon  the  person  of  M.  Robert  de  Welz, 
of  Wiirzburg,  with  the  effect  of  producing  only  chancroids.  Even  sup- 
posing that  Auzias  did  in  some  instances  employ  the  secretion  of  a  chancre, 
it  is  none  the  less  true  that  he  produced  merely  a  local  sore  and  that  there 
was  no  absorption  of  the  virus  into  the  system. 

M.  Auzias,  while  performing  these  experiments,  observed  that  the  first 
ulcer  inoculated  upon  an  animal  was  more  rapidly  developed,  was  of  a 
laro-CF  size,  secreted  a  greater  quantity  of  matter,  was  surrounded  by  more 
intense  inflammation,  and  was  more  persistent  than  the  second;  tliat  the 
second  bore  the  same  relation  to  the  third ;  tlic  third  to  the  fourth  ;  and 
so  on,  and  that  finally  a  period  arrived  Avhen  further  inoculations  entirely 
failed.  He  believed  that  at  each  inoculation  a  fresh  portion  was  absorbed, 
and  ascribed  the  final  immunity  to  saturation  of  the  system  with  the 
poison ;  when  no  more  could  be  taken  up,  as  he  thought,  he  said  that  the 
animal  was  "syphilized,"and  the  process  by  which  the  result  was  attained 
he  called  "sypiiilization." 

Reasoning  upon  this  basis,  M.  Auzias  inferred  that  the  same  result  could 
be  accomplished  in  man;  that  the  human  system  could  be  so  saturated 


SYPHILIZATION.  821 

Avith  the  sypliilitic  virus  by  repeated  inoculation  tliat  any  further  applica- 
tion of  the  poison  would  prove  innocuous;  and  in  1850  he  gravely  pro- 
posed to  the  Freneh  Academy,  not  only  to  employ  repeated  inoculations 
for  the  cure  of  syphilis,  but  to  "  syphilize"  the  greater  part  of  mankind  in 
order  that  they  might  never  have  syphilis  ! 

The  proposition  of  Auzias  to  employ  this  process  as  a  prophylactic 
against  syphilis  was  soon  abandoned,  if  for  no  other  reason,  on  account  of 
its  own  absurdity;  but '•  syphilization"  for  the  cure  of  syphilis  was  ex- 
tensively practised  by  Sperino,  of  Turin,  commencing  in  1851,  until  he 
was  forced  to  desist  by  the  opposition  it  excited. 

The  idea  thus  started  was  subsequently  taken  up  by  the  late  Prof.  W. 
Boeck,  of  Christiania,  who  devoted  yeai's  to  its  investigation,  and  who,  in 
18G2,  under  the  auspices  of  the  Norwegian  Government,  issued  a  large 
and  laborious  work,  in  which  were  reported  252  cases  treated  by  "syphili- 
zation," and  the  results  most  favorably  compared  with  those  obtainable  by 
mercury  and  other  modes  of  treatment. 

Prof.  Boeck  spent  a  portion  of  the  years  1869  and  1870  in  this  country, 
winning  the  admiration  and  the  esteem  of  all  who  knew  him,  by  his  purity 
and  gentleness  of  character,  and  his  enthusiasm,  and  affording  an  oppor- 
tunity to  witness  his  practice  in  my  wards  at  the  Charity  HospitaP  and 
elsewhere ;  but  he  fiiiled  to  make  converts  to  "  syphilization." 

In  the  last  edition  of  this  work,  considerable  space  was  devoted  to  an 
account  of  this  visit  of  Prof.  Boeck,  and  to  the  doctrines  and  practice  of 
syphilization.  This  treatment,  however,  may  now  be  said  to  be  dead,  as 
is  its  lamented  advocate,  and  we  shall  cont(nit  ourselves  with  only  a  very 
few  remarks  upon  it. 

In  the  first  place,  syphilization  is  based  upon  an  erroneous  supposition. 
The  matter  employed  in  these  inoculations,  whether  taken  from  chancroids 
as  in  Boeck's  earlier  practice,  or  from  irritated  chancres  as  in  his  later,  is 
nothing  but  chancroidal.  There  is  no  syphilitic  virus  in  it  with  which  to 
"  saturate  the  system,"  even  if  saturation  of  the  system  with  a  virus  in 
order  to  get  rid  of  the  same  virus  were  not  of  itself  an  absurdity.  Prac- 
tically, we  do  not  doubt  the  assertion  of  Prof.  Boeck  and  other  advocates 
of  syphilization,  that,  under  repeated  inoculations,  the  skin  acquires  a 
certain  immmiity  (which,  however,  we  believe  to  be  temporary),  but  this 
is  simply  in  accordance  with  tlie  general  law  that  the  integument,  under 
the  repeated  application  of  any  class  of  irritants,  will  finally  cease  to  react 
for  a  time.  Nor  do  we  doubt  that  syphilitic  lesions  disappear  and  fail  to 
reappear,  for  a  time  at  least,  under  this  treatment,  and  this  effect  can  only 
be  ascribed  to  the  eliminative  or  depurative  action  of  the  numerous  and 
constantly  repeated  ulcerations.  Trials  have  been  made  in  Christiania  and 
elsewhere  by  means  of  a  succession  of  blisters,  plasters  containing  tartar- 
ized  antimony,  etc.;  and  the  results  have  been  tlie  same.  Certainly,  no  mode 
of  treatment  can  be  more  repugnant  than  this  to  the  [)atient  himself. 

'  A  report  of  the  cases  treated  at  Cliarity  Hospital  may  be  loiinJ  in  tlie  Am.  J. 
M.  Sc,  Phila.,  July,  1870. 


822  TREATMENT    OF    SYPHILIS. 

In  the  cases  treated  at  Charity  Hospital,  the  patients  kept  their  beds 
during  the  greater  part  of  the  three  or  four  months  that  the  inocuhitions 
were  going  on,  although  they  had  every  inducement  to  be  up  and  out  upon 
the  grounds ;  and  it  often  required  all  our  powers  of  persuasion  to  lead 
tliem  to  consent  to  a  continuance  of  the  treatment,  so  great  was  their  dis- 
content. Indeed,  I  never  made  a  visit  to  the  hospital  without  the  fear 
that  some  of  them  had  eloped,  as  actually  happened  in  three  instances. 
They  represented  that  the  soreness  of  the  ulcerations  was  so  great  that 
they  could  scarcely  endure  the  contact  of  the  bedclothes,  much  less  that 
of  their  daily  dress,  and  the  appearance  of  the  sores  corroborated  their 
statement.  I  cannot  well  imagine  how  persons  in  their  condition  could 
have  been  about  attending  to  their  daily  business.  When  they  left  the 
liospital  they  bore  scars  over  the  chest,  arms,  and  thighs,  which  they  will 
doubtless  carry  with  them  to  their  graves.  Moreover,  the  serious  tend- 
ency of  some  of  the  ulcers  to  take  on  phagedenic  action  showed  that  this 
practice  is  not  devoid  of  danger. 


INDEX. 


ABNORMAL  positions  of  testis,  143 
Abortion,    mercury   as    a  cause    of, 
778 

Abortive  treatment  of  chancre,  4G6 
of  gonorrhoea,  48 

Acorn-pointed  sounds,  286 

Acne-form  sypbilide,  532 

Actual  cautery  in  chancroid,  368 
in  phagedisna,  389 

Adamkiewicz,  elimination  of  the  iodides, 
814 

Adenitis,  gonorrhoeal,  129 
chancroidal,  400 
syphilitic,  490 

Albuginitis,  syphilitic,  634 

Albuminate  of  mercury,  801 

Alibert,  varieties  of  vegetations,  243 

Alkalies  in  gonorrhoea,  54 

AUbutt,  Clifford,  sarsaparilla  in  syphilis, 
817 

Allingham,    treatment   of    rectal   gonor- 
rhoea, 212 

Alopecia,  syphilitic,  576 

Alyon,   nitric    acid  in  treatment    of    sy- 
philis, 817 

American  origin  of  S3'philis,  22 

"American  scale,"  280 

Anatomy  of  urethra,  250 

Aneurism  in  syphilis,  682 

Anger,  diagnosis  of  lingual  tumors,  594 

Anti-blennorrhagics,  63 

Aphasia,  syphilitic,  660 

Aphonia,  syphilitic,  623 

Arabian  treatment  of  syphilis,  788 

Arachnoid,  syphilis  of,  645 

Aromatic  wine,  204 

Arteries,  cerebral,  syphilis  of,  646 

Arteritis  syphilitica,  648 

Arthralgia,  687 

Aspiration   in   gonorrhoeal    rheumatism, 
240 

Aspirator,  324 

Asthenia  in  syphilis,  494 

Astringent  injections,  63 

Astruc,  syphilitic  orchitis,  633 

Atrophy  of  bone,  683 

Atropine  in  syphilitic  iritis,  712 

Aubert,  treatment  of  condylomata.  590 

Auspitz,  ciiancroidal  contagion,  345 
dilating  urethroscope,  90 


Auspitz — 

excision  of  chancres,  468 

pathological  anatomy  of  chancre,  463 

seat  of  buboes,  395 
Auzias  Turenne,  malignant  syphilides,  561 

syphilization,  821 


BABINGTON,  induration  of  chancre,  454 
relation   of  chancre   to   severity  of 
secondary  symptoms,  458 
Baerensprung,  herpes  inguinalis,  570 
Balz,  cutaneous  hemorrhage  in  syphilis, 

567 
Baumler,  poison  of  chancroid,  32 

ulcerations  of  larynx,  619 
Balanitis,  97 
causes,  97 
symptoms,  98 
complications,  99 
lymphitis,  99 
adenitis,  100 
penitis,  100 
diagnosis,  100 
treatment,  101 
Balneotherapia,  818 
Bamberger,  albuminate  of  mercurj',  801 
Bardinet,  chancre  of  finger,  474 
Barduzzi,  syphilis  of  rectum,  607 
Barlow,  hereditary  syphilis  of  the  nerv- 
ous system,  776 
Barker,  Prof.  Fordyce,  uterine  discharge 

as  a  cause  of  urethritis,  41 
Bassereau,  duration  of  chancre,  457 
frequency  of  chancroid,  346 
history  of  venereal  diseases,  21 
induration    of  ganglia   in    syphilis, 

480 
reaction  of  mucous  patches  upon  gan- 
glia, 589 
relation  of  chancre  to  severity  of  sec- 
ondary symptoms,  458 
seat  of  mucous  patches,  585 
symptoms  of  chancre,  448 
syphilitic  virus,  26 
Baumes,  syphilitic    eruptions   upon  mu- 
cous membranes,  583 
Bauingarten,  syphilis  of  cerebral  arteries, 

648 
Beadle,  dry  gonorrhoea,  40 


824 


INDEX. 


Beer,  sj'pliilis  of  spleen,  61 B 
Benique's  sound,  278 
Bell,  Cbas.,  acorn-pointed  bougies,  85 
ball-probes,  286 

specific  treatment  during  gestation, 
778 
Beranger-Ferand,  digitalis  in  gonorrhoea, 

55 
Bergh,  dactylitis  syphilitica,  673 
Bernutz  and  Goupil,  gonorrhoeal  ovaritis, 

200 
Bichloride  of  mercury,  793 
Bidenkap,  syphilitic  virus,  27 
Biesiadecki,  erythematous  syphilide,  517 
Biett,  papular  sypliilide,  521 
Bisulphate  of  carbon  iu  ulcerating  syphi- 

lides,  566 
Black  paste,  67 
Black  wash,  371 

Bladder  in  stricture  of  urethra,  272 
Blennorrhagia,  35 
Blisters  iu  gleet,  95 
Blood  in  syphilis,  487 
Bloodvessels,  syphilis  of,  631 
Bloody  semen,  182 
Boeck,  Prof.  W.,  chancroidal  poison,  342 

syphilization,  821 
Bones,  affections  of,  677 
treatment,  685 
cranial,  syphilis  of,  644 
Bonnet,  extirpation  of  eye,  225 
Boucheron,    chancre    of   semilunar    fold, 

698 
Bougies,  285 

in  gleet,  84 
Bouisson,  muscular  tumors,  666 

syphilitic  perichondritis,  686 
Bowman,    affections    of    lachrymal    pas- 
sages, 692 
Brain,  syphilis  of,  646 
Brandes,  gonorrhoeal  rheumatism,  232 
Breslau,  chancroid,  349 
Brodie,  Sir  Benj.,  mercurial  inunction,  779 

opium  in  retention  of  urine,  323 
Bronchi,  syphilis  of,  ()25 
Brown,   T.  R.,  malformations  in  heredi- 
tary syphilis,  736 
Bryant,  syphilitic  stricture  of  oesophagus, 

603 
Buboes,  394 
simple,  397 
virulent,  400 
frequency,  394 
seat,  395 
diagnosis,  406 
treatment,  407 
method  of  opening,  410 
complications,  404 
Bubon  d'emblde,  405 
Buck,  A.  H.,  syphilis  of  ear,  792 
Buck,  Gurdon,  perineal  fascite,  256 
Bull.  C.  S  ,  gummata  of  conjunctiva,  699 
Bullous  syphilide,  543 
Bursoe,  affections  of,  669 


Cachexia,  syphilitic,  493 
CamphtrscJdeim,  414 
Cannabis  sativa,  70 
Canquoin's  paste,  368 
Carbo-snlphuric  paste,  367 
Carbunculus  venereus,  560 
Caries,  syphilitic,  683 
Carmichael,  sti-ong  injections,  51 

tracheotomy    in    laryngeal    syphilis, 
626 
Cartilage,  affections  of,  686 
Caspary,  pathological  anatomy  of  chan- 
cre, 463 
Castelnau,  incubation  of  chancre,  447 

swelled  testicle,  131 
Cathartics  in  gonorrhoea,  54 
Catheters,  282 

mode  of  introducing,  290 
Caustics  in  phagedajna,  388 
Cauterization  of  chancroid,  366 
Cerebral  syphilis  sine  materia,  651 
Cernatesco,  chancres  iu  pregnant  woman, 

476 
Chabalier,  incubation  of  chancre,  447 
Chalons,   affections  of  lachrymal   gland, 

694 
Chancre,  445 
seat,  445 

anus,  472 
breast,  477 
buccal  cavity,  474 
extra-genital,  473 
finger,  473 
lip,  474 
urethra,  471 
uterus,  478 
incubation,  446 
symptoms,  448 
multiple  herpetiform,  450 
anomalous  appearance,  450 
induration,  451 
relapsing  induration,  455 
secretion,  456 
duration,  457 
termination,  457 
number,  458 
phagedenic,  458 
condition  of  ganglia,  459,  478 
diagnosis,  459 
pathological  anatomy,  462 
treatment,  466 
in  the  female,  475 
change  into  mucous  patch,  457 
Chancroid,  339 
history  of,  19 
from  contagion,  352 
from  inoculation,  351 
poison  of,  339 
frequency,  346 
seat,  348 

anus  and  rectum,  381 
eyelid,  695 
female  genitals,  377 
frtenum,  373 


INDEX. 


825 


Chancroid,  seat — 

inteo:ument  of  penis,  373 
sub-preputiiil,  374 
urethral,  377 

phagedenic,  383 

chronic,  of  prostitutes,  380 

development,  352 

period  of  progress,  354 

stationary  period,  355 

reparative  stage,  356 

number,  357 

varieties,  358 

diagnosis,  359 

prognosis,  363 

pathological  anatomy,  363 

treatment,  305 
general,  365 
abortive,  365 

excision  of,  468 
Chancroidal  bubo,  400 
Chancrous  erosion,  449 
Charcot,  syphilis  of  cerebral  arteries,  649 

syphilitic  epilepsy,  058 
Charri&re-filiere,  280 
Chassaignac,  dactylitis  syphilitica,  671 
Cheron,  treatment  of  condylomata,  590 
Chlorate  of  potash  in  stomatitis,  806 
Chloro-anasmia  in  syphilis,  493 
Cliordee,  74 
Chorea,  syphilitic,  661 
Choroiditis,  719 

Churchill's  tincture  of  iodine,  408 
Cicatrices,  in  bones,  684 

of  sj'philitic  ulcers,  515 
Ciliary  body,  affections  of,  718 
Circulatory  organs,  affections  of,  630 
Circumcision,  110 
Civiale,  number  of  strictures,  269 

urethrotome,  808 
Clarke,  Fairlie,  syphilis  of  tongue,  592 
Clerc,  chancrous  erosion,  449 

exulcerous  chancroid,  358 

incubation  of  chancre,  447 

inoculability  of  chancre,  456 

number  of  chancres,  458 

syphilitic  virus,  27 
Climate,  influence  of,  upon  syphilis,  820 
Cohen,  J.  Solis,  iodide   of   potassium  in 

laryngeal  syphilis,  625 
Colles'  law,  745 
Condylomata,  580 
Congenital  hydrocele,  157 
Conjunctiva,  affections  of,  697 
Cooper,  Sir  Astley,  gonorrhoeal  rheuma- 
tism, 228 

varicocele,  168 
Copaiba,  63 

eruption  caused  bj',  68 

experiments  with,  04 

mode  of  using,  68 

rectal  injectiotis,  68 

renal  congestion  caused  by,  09 
Cornea,  affections  of,  699 
Coruil,  gummata  of  stomach,  604 


Cornil  — 

gummata  of  liver,  610 

syphilitic  adenitis,  492 
Corona  veneris,  518 
Corpora  cavernosn,  affections  of,  126 
Coryza  in  hereditary  syphilis,  751 
Cowper's  glands,  inflammation  of,  125 
Cranial  bones,  s^'philis  of,  044 
Critchett,  mydriatics  in  syphilitic  iritis, 

715 
Crypta  syphilitica,  440 
Cubebs,  67 
Culierier,  chancroidal  poison,  342,  345 

copaiba  and  cubebs,  68 

syphilitic  enteritis,  603 

transmission  of  syphilis,  740 
Cupped  sound,  87 
Curling,  fungus  of  testicle,  635 

syphilitic  orchitis,  637 
Curvature    of  penis    after  internal    ure- 
throtomy, 319 
Cutaneous  hemorrhage  in  syphilis,  507 
Cyclitis,  syphilitic,  718 
Cystitis,  178 

treatment,  180 


DABRY,  Capt.,  syphilis  in  China,  23 
Dactylitis  sypliilitica,  670 
Dalby,  deaf-mutism  in  hereditary  syphilis, 

734 
Davasse,  mucous  patches,  584 

change  of  chancre  into  mucous  patch, 
458 
Deafness  produced  by  syphilis,  732 
Debauge,  number  of  chancres,  458 

number  of  chancroids,  357 

seat  of  chancroids,  348 
Debeney,  strong  injections,  51 
Demarquay,  stricture  of  trachea,  024 
Desmarres,  syphilitic  tubercles  of  ocular 

membrane,  698 
Denis,  endoscope,  89 
Depaul,  hereditnry  syphilis  of  lungs,  754 

hereditary  syphilis  of  thymus  gland, 
764 
D^sormeaux,  endoscope,  88 

endoscope  in  gonorrhoea,  46 
Desprgs,  nature  of  syphilis,  440 
Deville,  chronic  syphilitic  tetanus,  066 

mucous  patches,  584 
De  M6ric,  nuifous  patches,  590 
I)e  I'aoli,  iuMiiorrhagic  bubo,  404 
Dick,  Henry,  sonde-tourniquet,  304 
Diday,  chancroidal  poison,  342 

chancrous  erosion,  450 

expectant  treatment  of  gonorrhoea,  71 

expectant  treatment  of  syphilis,  787 

extra-genital   gonorrhoea,  211 

hereditary  sypliilis,  745 

hereditary  syphilis  of  liver,  757 

iiicul)ation  of  chancre,  447 

relation    of   chancre    to    severity   of 
secondary  symptoms,  459 


826 


INDEX. 


Diday — 

second  period  of  incubation  in  syphi- 
lis, 487 
self-limitation  of  syphilis,  503 
syphilitic  re-infection,  421 
treatment  of  epididymitis,  148 
urethritis  caused  by  menstrual  dis- 
charge, 41 
Dieulafoy,  aspirator,  325 
Digestive  organs,  affections  of,  591 
Digitalis  in  gonorrhoea,  55 
Diphtheroid  of  glans  penis,  450 
Dixon,  gonorrhoeal  ophthalmia,  226 

syphilitic  strabismus,  727 
Donue,  infusoria  in  vaginitis,  189 
Dowse,  hereditary  nervous  syphilis,  777 
Dron,  syphilitic  epididymitis,  633 
Dry  caries,  683 
Dry  chancre,  451 
Dry  treatment  of  syphilis,  788 
Dubois,    hereditary   syphilis    of    thymus 

gland,  763 
Duboisiae  as  a  mydriatic,  715 
Dubuc,    multiple    herpetiform   chancres, 

450 
Duplay,  syphilis  of  rectum,  607 
Dupuytren,  necrosis  of  skull,  682 
Dura  mater,  syphilis  of,  645 


EAR,  acquired  syphilis  of,  729 
hereditary  syphilis  of,  734 
Ecthyma-form  syphilide,  538 
Eczema,  marginatum,  570 

of  scrotum  and  penis,  569 
Elsberg,  stricture  of  larynx,  618 
Encysted  hydrocele,  158 
Endoscope,  87 

Eno,  H.  C,  gummous  scleritis,  704 
Epididymitis,  gonorrhoeal,  130 

causes,  131 

seat,  133 

symptoms,  135 

pathological  anatomy,  143 

termination,  137 

treatment,  145 

syphilitic,  633 
Epilepsy,  syphilitic,  658 
Episcleritis,  syphilitic,  702 
Eruption  fever,  488 
Erythema  of  mucous  membranes,  583 
Erythematous  syphilide,  516 
Erysipelas,  effect  of,  on  syphilides,  513 
Excision  of  chancres,  467 
Exophthalmos,  691 
Exostoses,  syphilitic,  680 
Expectant  treatment,  of  gonorrhoea,  71 

of  syphilis,  787 
Exploration  of  urethra,  278 
Extravasation  of  urine,  329 
Eye,  acquired  syphilis  of,  690 

hereditary  syphilis  of,  728 
Eyelids,  affections  of,  694 


FALLOPIAN  tubes,  syphilis  of,  640 
Fasciffi,  perineal,  253 
Ferras,  Pierre,  mucous  patches  of  larynx, 

620 
Fever,  syphilitic,  488 
Fingers,  affections  of,  671 
FiJrster,  choked  disk,  724 

choroiditis  syphilitica,  722 
hereditary  syphilis  of  intestine,  756 
Folet,  stricture  of  urethra,  268 
Folliculitis,  120 

Follin,  syphilitic  necrosis  of  skull,  683 
Foster,  Frank  P.,  vaginal  douche,  203 
Foucart,  gonorrhoeal  rheumatism,  231 
Fournier,  alopecia  sj-philitica,  577 
chancre,  incubation  of,  447 

of  uterus,  478 
chancroid,  development,  353 
frequency,  347 
seat,  348 
chloro-anoemia  and  asthenia  in  syphi- 
lis, 494 
cystitis,  diagnosis  of,  180 
disorders  of  general  sensibility,  508 
dorsal  hygroma,  068 
expectant  treatment  of  gonorrhoea, 

71 
ganglia  in  syphilis,  479 
gonorrhoea,  42,  45 
gummous  syphilide,  seat  of,  551 
mixed  chancre,  391 
onychia,  hypertrophic,  579 

sicca,  578 
phagedenic  bubo,  403 
pigmentary  syphilide,  558 
pseudo-general  paralysis,  601 
pulmonary  syphilis,  628 
purpura  from  iodide  of  potash,  816 
syphilis  of  rectum,  606 
sublingual  gland,  syphilis  of,  595 
tertiary  syphilides  of  tongue,  593 
urethral  rheumatism,  230 
Fox,  G.  II.,  pigmentary  syphilide,  558 
Fox,  Tilbury,  hydroa  from   iodide  of  po- 
tassium, 815 
France,  secondary  eruption    of    the  con- 
junctiva, 697 
Frliiikel,    Ernst,    affections   of    placenta, 

781 
French  disease,  24 
Fricke,  strapping  the  testicle,  149 
Friedliinder,  syphilis  of  cerebral  arteries, 

648 
Fumigation,  mercurial,  795 


GALEZOWSKI,  chancroid  of  eyelid,  695 
Gralippe,  contagion  of  syphilis,  433 
Galloping  syphilis,  535 
Gama,  syphilis  of  facial  bones,  645 
Gambarini,  biniodide   of  mercury  hypo- 

dermically,  802 
Ganglia  in  chancroid,  358 
Gangrene,  spontaneous  in  syphilis,  562 


INDEX. 


827 


Gangrenous  cbancroid,  383 

Gardien,  infection  of  mother  by  syphilitic 

foetus,  744 
Gee,  hereditary  syphilis  of  spleen,  759 
Gelatum  petrolei,  564 
Gelsemium  in  gonorrhoea,  69 
Genitals,  affections  of,  569 
Gerhardt,  stenosis  of  trachea,  623 

seat  of  laryngeal  syphilid,  617 
Gestation,  use  of  mercury  during,  778 
Gibert's  formula,  792 
Glands  of  Littre,  252 
Gleet,  78 

diagnosis,  79 
infection,  81 
origin,  79 
pathology,  81 
symptoms,  80 
treatment,  82 
Godard,  effect  of  epididymitis  upon  sexual 

power,  143 
Gonorrhoea,  36 
"dry,"  39 
history  of,  18 
hemorrhage  in,  38,  75 
in  the  male,  36 

causes  and  nature,  40 
lesions,  46 
treatment,  47 
in  the  female,  186 
symptoms,  188 
diagnosis,  200 
treatment,  201 
leucorrhceal  origin  of,  41 
duration  of,  39,  46 
without  contagion,  42 
from  asparagus,  43 
from  sexual  excitement,  43 
of  the  mouth,  212 
of  the  nose,  213 
of  the  rectum,  211 
of  the  seminal  vesicles,  182 
of  the  umbilicus,  213 
of  the  urethrsi,  197 
of  the  uterus,  196 
of  the  vulva,  189 
Gonorrhoeal  ophthalmia,  214 
causes,  216 
symptoms,  217 
diagnosis,  220 
treatment,  220 
Gonorrhoeal  peritonitis,  184 
Gonorrhoeal  prostatitis.  170 
Gouorrhijeal  rheumatism,  227 
causes,  229 
diagnosis,  237 
frequency,  230 
seat,  231 
symptoms,  233 
treatment,  239 
Goodhart,  pulmonary  syphilis,  627 
Gosselin,     effect    of    epididymitis     upon 
sexual  power,  140 
gummy  tumor  of  saphena  vein,  631 


Gosselin — 

hypertrophy  after  chancroids   of  fe- 
male genitals,  381 

syphilis  of  rectum,  005 
Gowers,  syphilis  of  cerebral  arteries,  649 
Graefe,  paralysis  of  nerves  of  eye,  725 

tubercles  of  iris,  711 
Granuloma,  442 
Grassi,  blood  in  syphilis,  487 
Green,  amj'loid  degeneration  of  liver,  611 

syphilis  of  arteries,  632 
Greenfield,  pulmonary  syphilis,  627 
Gruber,  exostoses  of  bones  of  ear,  730 

mucous  patches  of  ear,  731 
Gruening,  spongy  iritis,  718 
Gubler,  hereditary  syphilis  of  liver,  757 
Guilland,  gouty    diathesis   and    urethral 

discharge,  43 
Guillaumet,  ulcerating  syphilides,  566 
Gummous  syphilide,  549 

seat,  551 

of  head  and  face,  682 

of  heart,  630 

of  lungs,  628 

of  soft  palate,  596 

of  tongue,  593 
Gurjun  balsam,  70 
Guyot,   contraction  of  jaws  in   syphilis, 

668 
Oypstheer,  414 


HAECKEL,  process  of  procreation,  738 
Hair,  afl'ections  of,  576 
Hammond,  Wni.   A.,  pyajmia  after  open- 
ing a  bubo,  405 
Handerson,  H.  E.,  gauge  for  measuring 

instruments,  281 
Hardy,  injection  of  urine  containing  co- 
paiba, 64 
pigmentary  syphilide,  558 
roseola  of  tongue,  592 
Harrison,    Reginald,    urethral   discharge 

caused  by  asparagus,  43 
Heart,  syphilis  of,  630 
Hebra,  eczema  marginatum,  570 
ointment  for  eczema,  571 
phagedtena,  388 
Hematocele,  of  the  cord,  163 

of  the  testis,  162 
Hemorrhage,  in  gonorrhoea,  75 
in  syphilis,  567 

after  operating  for  stricture,  318 
Hemorrhagic  l)ubo,  404 
Henderson,  Thos.  C,  oil  of  yellow  san- 
dal-wood, 70 
Henoch,  hereditary  syphilis  of  testicle, 

761 
Henry,  M.  H.,  exulceratlve  hypertrophy 
of  neck  of  uterus,  640 
phimosis  forceps,  110 
Hereditary  syphilis,  735 

duration  and  progress,  737 
invasion  and  evolution,  746 


828 


INDEX. 


Hereditary  syphilis — 

parental   iuflueuce    in   transmission, 

739 
treatment,  777 

affections  of  alimentary  canal,  756 
blood,  7t'i5 
bones,  706 

circulatory  organs,  705 
hair,  703 
joints,  773 
kidneys,  760 
larynx,  754 
liver,  757 
lungs,  754 

lymphatic  ganglia,  764 
mucous  membranes,  751 
■  nails,  702 
nervous  system,  774 
pancreas,'  700 
peritoneum,  756 
spleen,  75') 

supra-renal  capsules,  761 
synovial  sheaths,  702 
testicle,  703 
thymus  gland,  763 
umbilical  vein,  705 
Herpes,  inguinalis,  570 

progenitalis,  210 
Heubner,  syphilis  of  cerebral  arteries,  646 
Hewson's  earth  injections,  02 
Hill,  Berkeley,  iodoform,  816 
Hirscher,  chancroid  of  eyelid,  695 
Hirschfeld,    hereditary    syphilis    of    the 
pancreas,  700 
of  the  spleen,  759 
Holt,  rupture  of  stricture,  310 
Horand,  ice  in  vesical  tenesmus,  180 
Hot  Springs  of  Arkansas,  819 
Hot  immersions  in  gonorrhoea,  54 
Howse,  H.  G.,  traumatic  stricture,  328 
Hue,  operation  for  phimosis,  113 
Hugonneau,  syphilis  of  tongue,  593 
Huguier,  sebaceous  vulvitis,  191 
Hulot,  chancre  of  ear,  729 
Hunter,  induration  of  chancre,  452 
infectiousness  of  gleet,  81 
seat  of  syphilitic  lesions,  427 
Hutchinson,    Jonathan,    syphilis    among 
the  Jews,  104 
hereditary  syphilis,  of  ear,  734 

of  nervous  system,  776 
hydroa  from  iodide  of  potash,  816 
infection    of    mother    by    syphilitic 

child,  745 
origin  of  local  venereal  sore,  32 
strumous  corneitis,  700 
Hutinel,  hereditary  syphilis  of  testicle,  762 
Hyde,  J.  Nevins,  tayuya,  818 
Hydrastin,  03 

Hydroa  from  iodide  of  potash,  815 
Hydrocele,  155 

diagnosis,  156 
treatment,  156 
of  the  spermatic  cord,  159 


Hygiene  in  syphilis,  788 

Hygroma,  608 

Hypodermic  injections  of  mercury,  799 


ICK,  in  epididymitis,  148 
in  vesical  tenesmus,  180 
Ichthyosis  of  tongue,  592 
Icterus,  009 

Immersion  treatment  of  chancroids,  388 
Impermeable  stricture,  270 
Impetigo-form  syphilide,  536 
Indurated  ganglia  in  syphilis,  479 

constancy,  479 

seat,  481 

time  of  appearance,  482 

symptoms,  483 

course  and  termination,  483 

diagnosis,  485 

treatment,  486 
Induration  of  chancre,  451 

of  epididymis,  153 

of  lymphatics  in  syphilis,  485 
Indurations  de  voisinage,  455 
Infantile  iritis,  717 
Inferior  penile  chamber,  258 
Inflammation  of  vulvo-vaginal  gland,  1  92 
Inflammatory  chancroid,  383 
Injections,  mode  of  using,  50,  59 

in  gleet,  91 

in  gonorrhoea,  57 

of  hydrastin,  63 

of  Hewson's  earth,  62 

of  urine  containing  copaiba,  64 
Injection  Bru,  61 
Internal  urethrotomy,  303 
Intestines,  syphilis  of,  003 
Inunction,  mercurial,  798 
Iodide  of  potassium,  in  syphilis,  811 

in  rectal  stricture,  008 

effect  on  genitals,  814 

effect  on  skin,  815 
lodism,  810 
Iodoform,  816 

in  chancroid,  370,  388 

in  swelled  testicle,  153 
Iritis,  syphilitic,  708 

simple,  708 

serous,  710 

parenchymatous,  710 

spongy,  718 

treatment,  713 


JACKSON,      Hughlings,  syphilitic    epi- 
lepsy, 659 
hereditary  syphilis  of  nervous   sys- 
tem, 775 
Jaques's  catheter,  284 
Jarnowski,  digitalis  in  gonorrhcei,  55 
Jarjavay,  perineal  fasciae,  257 
Jaws,  contraction  of,  in  syphilis,  068 
Joints,  affections  of,  687 
Jones,  Prof.  Jos.,  origin  of  syphilis,  22 


INDEX. 


829 


Jullien,  chancres  of  nnus,  472 

gummata  of  head  and  face,  68i: 
papuhir  syphilide,  521 


KAPOSI,  chancre,  462 
chancroid,  363 

inoculation  of  non-specific  pus,  oO 
Kassowitz,  infection  of  mother  by  syphi- 
litic foetus,  744 
mortality  in  hereditary  syphilis,  735 
Keratitis,  syphilitic,  699 
Keyes,  E.  L.,  affections  of  bursse,  670 

eti'ect  of  mercury  upon  the  blood,  803 
Kidneys,  in  stricture,  272 

syphilis  of,  641 
Klink,  venereal  sores  of  the  female  geni- 
tals, 378 
Knapp,  H..  syphilitic  strabismus,  727 
Kobner,  hereditary  syphilis  of  bones,  767 
Koster,  syphilis  of  cerebral  arteries,  648 
KoHiker,  excision  of  chancre,  468 
Krisbaber,  erythema  of  larynx,  619 
laryngeal  syphilis,  624 


LACHRYMAL    GLAND,    affections    of, 
694 
Lachrymal  passages,  affections  of,  692 
Lacombe,  syphilis  of  liver,  612 
Lacuna  magna,  252 
Lafayette  mixture,  65 
Lagneau,  syphilitic  exostoses,  680 

syphilis  of  tongue,  594 
Lamaller^e,  caries  of  laryngeal  cartilages, 

622 
Lancereaux,  papule  eeche,  451 
syphilis,  of  arteries,  632 
of  bones,  679 
of  kidneys,  641,  760 
of  lungs,  626 
of  ovaries,  640 
of  pancreas,  614 
of  rectum,  (;05 

of  stomach  and  intestines,  604 
Larynx,  syphilis  of,  616 
general  symptoms,  617 
classification,  617 
erythema,  619 
superficial  ulcerations,  619 
mucous  patciies,  620 
chronic  inflammation,  621 
deep  ulcerations,  621 
gummy  tumors,  622 
perichondritis,  622 
caries,  622 
treatment,  624 
Latent  gonorrhoea  in  women,  209 
Latour,   sexual    excitement   a    cause    of 

gonorrhoea,  44 
Laurenzi,  gummata  of  the   peritoneum, 

604 
Lawrence,    Mr.   William,  phimosis    com- 
plicating chancroids,  384 


Learning,  muco-purulent  conjunctivitis  in 

children,  42 
Lebert,  microscopicalappearances  of  vege- 
tations, 243 
pathology  of   hereditary  syphilis  of 
lung,  754 
Lee,    Mr.    Henry,    auto-inoculability    of 
chancre,  457 
calomel  by  fumigation,  795 
discharge  from  cliancroid,  355 
syphilitic  virus,  27 
operation  for  varicocele.  166 
Lefferts,  Dr.  Geo.  M,  affections  of  larynx 

in  hereditary  syphilis,  754 
Lens,  affections  of,  718 
Leontiasis  syphilitica,  523 
Lewin,  hypodermic  use  of  mercury,  800 
Liegois,  effect  of  epididymitis  upon  sex- 
ual power,  142 
effect  of  mercury,  803 
Lister,  impermeable  stricture,  270 
Liver,  syphilis  of,  609 

chronic  interstitial  hepatitis,  609 
gummata,  010 
amyloid  degeneration,  611 
Lloyd,  Dr.  Edwin,  treatment  of  epididy- 
mitis, 146 
Locomotor  ataxia,  661 
Loomis,  Prof.  A.  L.,  syphilitic  myocar- 
ditis, 630 
Lungs,  syphilis  of,  626 
Lupus  erythematosus  of  penis,  575 
Lupus  syphiliticus,  549 
Lutz  and  Personne,  analysis  of  milk  dur- 
ing use  of  mercury.  779 
Lymphangitis,  gonorrhoeal,  128 
Lymphatics  in  .syphilis,  443 
Lymphitis,  416 


M 


,,,  ACKENZIE,  secondary  ulcers  of  eye- 
ill     lid,  696 
Magin,  ulceration  of  cornea,  698 
Maisonneuve,  ui-ethrotome,  305 
Malapert,  treatment  of  buboes,  414 
Matassez,  gummy  tumor  of  liver,  610 
Malignant  precocious  syphilide,  559 
Markoe,  Prof.  T.  M.,  operation  for  vari- 
cocele, 167 
Martin,  exulcerative  hypertrophy  of  neck 
of  uterus,  640 
period  of  development  of  syphilitic 
lesions,  428 
Marty,  gonorrhoeal  rheumatism,  232 
Matico  capsules,  68 
Maunther,  punctate  keratitis,  702 
Mauriac,  erysipelas  and  lesions  of  syphilis, 
513 
erythema  of  the  larynx,  619 
frequency  of  chancroid,  347 
infecting  balano-postliitis,  451 
phlegmonous       intlammation       after 

caries  of  laryngeal  cartilage,  623 
neuralgic  herpes,  247 


830 


INDEX. 


Mauriac — 

reflex  neuralgias  in  epididymitis,  137 

syphilitic  osseous  affections,  677 

sj'philitic  lesions  of  the  muscles,  GG4 
Maurv,  l^rof.  F.  F.,  fumigating  apparatus, 

'  797' 

syphilitic  stricture  of  oesophagus,  (J03 
Maxillary  bones,  necrosis  of,  5U;') 
McCready,  Prof.  B.  W.,  sloughing  bubo, 

405 
McMasters,  treatment  of  syphilitic  stric- 
ture of  rectum,  6U8 
^leatometers,  287 
IMedicated  bougies  in  gleet,  86 
Jlelsens  and  Guillot,  iodide  of  potassium 

in  syphilis,  811 
Meningitis,  syphilitic,  654 
Mercier,  eczema  from  iodide  of  potassium, 

815 
Mercurials  in  treatment  of  syphilis,  790 
Mercury,  as  a  cause  of  iritis,  713 

as  a  cause  of  osseous  affections,  678 
Mickle,  pseudo-general  paralysis,  662 
Milk,  effect  of  mercury  upon,  779 

contagiousness  of,  431 
Milton,  J.  L.,  camphor  in  chordee,  74 

treatment  of  epididymitis,  147 

treatment  of  gleet  with  blisters,  95 

treatment  of  gonorrhoeal  rheumatism, 
241 
Mireur,  contagiousness  of  semen,  431 
Mixed  chancre,  390 

Moissenet,  stricture  of  the  trachea,  624 
Mooren,  syphilitic  retinitis,  723 
Mouth,  affections  of,  591 

treatment,  599 
Morgan's  suspender  for  varicocele,  165 
Morrow,  Dr.   P.  A.,    diphtheroid    of   the 

glans,  450 
Mortality  in  hereditary  syphilis,  735 
Moxon,  syphilis  of  cerebral  arteries,  649 
Mucous  membranes  in  sy()hilis,  507 
jNIucous  membranes,  affections  of,  583 

erythema,  583 

mucous  patches,  584 
Mucous  patches,  584 

treatment,  589 
Muscles,  affections  of,  6G4 
Mydriatics,  714 
Myocitis,  syphilitic,  6G4 

NAILS,  affections  of,  578 
Necrosis,  of  cranial  bones,  form  of,  683 
of  maxillary  bones,  595 
Nelaton,  syphilitic  orchitis,  687 
Nervous  system,  affections  of,  643 
classification,  644 
bones,  644 
dura  mater,  645 
arachnoid  and  pia  mnter,  645 
brain  and  cord,  646 
arteries,  646 
nerves,  649 


Nervous  system — 

prodromal  symptoms,  651 

tumors  of,  653 

treatment,  662 
Neuralgic  herpes,  247 
Nitrate  of  silver  injections,  48 
Nocturnal  pains  in  syphilis,  679 
Nodes,  syphilitic,  679 
Noeggerath,  I»r.  Emil,  latent  gonorrhoea 

in  women,  209 
Nose,  syphilis  of,  615 

treatment,  616 
Notta,  syphilitic  affections  of  muscles,  664 
Noyes,  Prof.  H.  D.,  syphilitic  iritis,  708 

ulceration  of  cornea,  698 


ODOR  of  syphilitic  lesions,  515 
Oedmansson,  lesions  of  the  umbilical 
vein  in  hereditary  syphilis,  765 
Esophagus,  syphilis  of,  (JOl 
Oewi-e,  transmission  of  syphilis,  743 
Ointments  in  treatment  of  chancroids,  371 
Onychia,  in  acquired  syphilis,  578 

in  hereditary  syphilis,  763 
Opaline  patches,  588 
Ophthalmia  complicating   gonorrhoeal 

rheumatism,  236 
Opiated  injections  in  gonorrhoea,  56 
Optic  nerve,  affections  of,  724 
O'Keilly,  Dr.  .John,  bullous  eruption  pro- 
duced by  iodide  of  potash,  815 
Orbital  bones,  affections  of,  690 
Orchitis,  gonorrhoeal,  130 
Orchitis,  syphilitic,  633 
symptoms,  634 
pathological  anatomy,  635 
diagnosis,  636 
treatment,  638 
Ory,  malignant  syphilides,  561 
Osseous  affections,  677 

mercury  as  a  cause  of,  678 
Osteocopic  pains,  679 
Osteomyelitis,  681 
Osteo-periostitis,  syphilitic,  679 
Otis,  Prof.  F.  N.,  cold-water  coil,  75 
gleet  in  relation  to  stricture,  84 
nature  of  syphilis,  443 
perineal  tourniquet,  319 
pus  of  acute  ophthalmia  as  a  cause 

of  gonorrhoea,  42 
spasmodic  stricture,  264 
uretlirometer,  288 
uretlirotome,  307 
Ovaries,  syphilis  of,  640 
Ovaritis  complicating  gonorrhoea,  199 
Over-medication  in  gouorrhoe.i,  73 


PAGET,   Sir  James,  sexual  intercourse, 
334 
masturbation,  337 

relation  between  syphilis  and  gout, 
499 


INDEX. 


831 


Panaris,  syphilitic,  671 
Pancrens,  syphilis  of,  614 

lesions  of.  in  hereditary  syphilis,  760 
Papular  syphilide,  5:20 

miliary,  520 

lenticular,  522 
small,  522 
large,  525 

scaling,  529 
Paralysis,  of  the  nerves  of  the  eye,  725 

pseudo-general,  G61 
Paraphimosis,  114 

treatment,  1 16 
Paraplegia,  syphilitic,  659 
Parchment  induration,  45o 
Pardova,  contagiousness  of  milk,  431 
Parker,  Langstou,  eifect  of  iodine  upon 
the  tongue,  816 

mercurial  fumigation,  795 

method  of  opening  buboes,  413 
Parrot,  hereditary  syphilis  of  bones,  767 

hereditary  syphilis  of  kidney,  761 

hereditary  syphilis  of  spleen,  759 

histology  of    hereditary   syphilis  of 
testicle,  762 
Paul,  TI.  J.,  adhesions  in  fauces  following 

syphilitic  ulceration,  597 
Pellizzari,    contagiousness    of    syphilitic 
blood,  481 

vehicles  of  syphilitic  poison,  742 
Pelvic  fascia,  258 
Pemphigus  syphiliticus,  535 
Penis,  eczema  of,  569 

lupus  erythematosus  of,  575 

syphilis  of,  639 
Perichondritis,  syphilitic,  686 
Perineal  fasciae,  253 
Perionychia,  579 
Peri-urethral  phlegmon,  121 
Petit,  J.  L.,  syphilis  and  traumatism,  500 
Petron,  syphilis  of  sympathetic  nerves,  650 
I'eyer's  patches,  lesions  of,  in  hereditary 

syphilis,  756 
I'hagedenic  bubo,  402 
Phagedenic  chancroid,  385 
Pharynx,  syphilis  of,  598 

treatment,  599 
Phillips,    slitting   the   lacuna    magna   in 

gleet,  82 
Phimosis,  104 

congenital,  104 

accidental,  106 

treatment,  107 
I'htheiriasis  pubis,  572 
I'Ui  mater,  syphilis  of,  045 
Pick,  inoculation  of  syphilitics  with  sim- 
ple pus,  128 
Piffard,   Prof.    H.  G.,   actual   cautery  in 
chancroids,  368 

meatometers,  287 
Pigmentary  syphilide,  558 
Pigmentation,  lotions  in  treatment  of,  563 
rilul.-e  copaibte,  66 
Pityriasis  versicolor,  573 


Placenta,  afifections  of,  781 

Plenck's  gummy  mercury,  779 

Plumbe,  Samuel,  ichthyosis  of  the  tongue, 

592 
Podres,    spontaneous    gangrene    in    the 

course  of  syphilis,  562 
Potain,  aspirator,  325 
Poultices  in  epididj'mitis,  149 
Procreation,  738 
Prostatic  chamber,  259 
Prostatitis,  170 
Prostatorrhoea,  174 
Pseudo-general  paralysis,  061 
Pseudo-rheuuiiitism,  syphilitic,  687 
Psoriasis  syphilitica,  529 

treatment,  564 
Psoriasis  of  the  tongue,  592 
Puche,  frequency  of  chancroid,  346 

induration  of  chancre,  455 
Pulsatilla  in  epididymitis,  148 
Puncture  of  the  bladder,  326 
Purpura  from  iodide  of  potash,  816 
Pustular  syphilide,  531 

acne-form,  532 

variola-form,  534 

impetigo-form,  536 

ecthyma-form,  538 

rupia,  541 


RABOT,  syphilis  of  cerebral  arteries,  648 
Rayer,  syphilitic  Bright's  disease,  641 

Rectum,  syphilis  of,  605 

Relapsing  indurations,  455 

Respiratory  organs,  affections  of,  615 

Retention  of  urine,  treatment,  321 

Retinitis,  syphilitic,  722 

Reynaud,  treatment  of  buboes,  414 

Rhagades,  587 

Rheumatism,  gonorrboeal,  227 
syphilitic,  687 

Richet,  perineal  fasciro,  258 

syphilitic  white  swelling,  689 

Ricord,  chancroidal  poison,  342 

chlorate  of  potash  in  mercurial  stom- 
atitis, 807 
"  choc  en  retour"  744 
strange  effects  of  copaiba,  69 
experiments  with  copaiba,  64 
diagnosis  of  tumors  of  testis,  634 
erythema  of  mucous  membranes,  582 
gonorrboeal  rheumatism,  233 
induration  of  chancre,  453 
induration  of  ganglia  in  syphilis,  479 
law  of  syphilitic  contagion,  430 
nocturnal  pains  of  syphilis,  679 
osteo-niyelitis,  681 

ovaritis  complicating  gonorrhoea,  199 
specific  treatment  during  gestation, 

778 
syphilis  of  penis,  639 
syphilitic  albuginitis,  634 
syphilitic  eruption  upon  mucous  mem- 

/  branes,  5c3 


832 


INDEX. 


Piicoi'd — 

termination  of  chancre,  457 
treatment,  of  buboes,  410 
of  phagedajiia,  'SS7 
of  syphilitic  orchitis,  638 
urethral  discharge    from    tubercular 

deposit,  48 
unicity  of  syphilis,  4-1 
classification  of  syphilitic  symptoms, 
423 
Ricordi,  chancroidal  poison,  343 
Kochebrune, diagnosis  of  hereditary  syphi- 
lis of  liver,  758 
Rollet,  chronic  chancroid  of  prostitutes, 
380 
gonorrhoeal  rheumatism,  229 
indurated  ganglia,  482 
mixed  chancre,  392 
pulmonary  sypliilis,  629 
result  of  syphilitic  orchitis,  635 
suppuration  of  syphilitic  bubo,  484 
sypbilitic  virus,  27 
treatment  of  chancroids  of  anus  and 
rectum,  382 
Rosennililler's  gland,  395 
Roseola  syphilitica,  516 
Royet,  inversions  du  lesiicule,  134 
Rupia,  541 


SAINT-PHILLIPPE,  arsenic  as  a  cause 
of  urethritis,  43 

Salisbury,  Prof.  J.  II.,  crypta  syphilitica, 
341,  440 

Salivation,  805 

Salmon,  gonorrhoea  in  vyomen,  193 

Saltzman,  exostosis  of  parietal  bone,  680 

Sandal-wood  oil,  70 

Sarcocele,  syphilitic,  634 

Sass,  Louis  F.,  atomizers,  599 

Savy,  syphilitic  papule  of  the  conjunctiva, 
697 

Scabies  of  the  genital  organs,  57 

Scanzoni,  treatment  of  gonorrhoea  in  wo- 
men, 206 

Scarenzio,    preparation   of    mercury    for 
hypodermic  use,  800 

Schott,  sypliilis  of  nerves,  650 

Schwartze,  syphilis  of  ear,  734 

Sclera,  afl'ections  of,  702 

Scleritis  syphilitic,  703 

Sclerosis  of  the  tongue,  593 

Scrotum,  eczema  of,  569 

Sebaceous  vulvitis,  Huguier,  191 

Sedatives  in  epididymitis,  147 

Semen,  infection  by,  431,  746 

Serpiginous  chancroid,  385 
syphilide,  555 

Sexton,    Dr.    Samuel,    sudden    deafness 
caused  by  syphilis,  732 

Sexual  hypochondriasis,  332 

Sigmund,  induration  of  chancre,  454 
mercurial  inunction,  798 
sarsaparilla  in  syphilis,  817 


Sigmund,  treatment  of  bubo,  409 
Simple  bubo,  397 
chancre,  339 
Simpson,  treatment  of  gonorrhoea  in  wo- 
men, 206 
Simyan,  gummy  tumors  of  larynx,  622 
Skeene,  l)r.  T.,  endoscope,  377 
Skin  in  syphilis,  507 
Sloughing  phagedenic  chancroid,  386 
Smee,    secondary    eruption    on   the   con- 
junctiva, 697 
Smith,  Dr.  And.   H.,  impromptu  aspira- 
tor, 324 
Soft  chancre,  339 
Soft  palate,  gummy  tumor  of,  596 
Sommerbrodt,  stricture  of  larynx,  619 
Sonde-tourniquet,  304 
Sounds,  284 

Speculum  in  gonorrhoea  of  women,  193 
Sperino,  inflammatory  chancroid,  383 

syphilization,  821 
Spinal  cortl,  syphilis  of,  646 
Spleen,  syphilis  of,  612 
Spongy  iritis,  718 

Squibb,  Dr.  E.  R.,  solution  of  the  albumi- 
nate of  mercury,  802 
Squire's  vertebrated  catheter,  284 
Staphyloma    following    gonorrhoeal   oph- 
thalmia, 224 
Staub,  albuminate  of  mercury,  801 
Stearns,  artificial  palate,  597 
Stern,  hypodermic  use  of  mercury,  801 
Stewart,  Dr.  F.  Campbell,  instrument  for 

strong  injections,  52 
Stomatitis  from  mercury,  805 
Stomach,  syphilis  of,  603 
Strabismus,  sj'philitic,  727 
Strapping  the  testicle  in  epididymitis,  149 
Stricture,  of  the  ojsophagus,  601 
of  the  rectum,  605 
of  the  larynx,  618 
of  the  trachea,  023 
of  the  urethra,  250 
spasmodic,  263 
organic,  265 
seat  of,  265 
number,  268 
form,  269 

degree  of  contraction,  270 
pathology,  270 
s^'mptoms,  273 
causes,  275 
diagnosis,  277 
treatment,  294 
Sub-lingual  gland,  595 
Sulphur  Springs,  819 
Sulphurous  acid  in  eczema  marginatum, 

571 
Suppositories  of  mercury,  799 
Supra-renal  capsules,  affections  of,  in  he- 
reditary syphilis,  761 
Suspensory  bandages  in  gonorrhoea,  53 
Swelled  testicle,  130 
Syme,  impermeable  stricture,  270 


INDEX. 


833 


Syme's  operation,  312 
Sympathetic  nerves,  syphilis  of,  650 
Synovitis,  syphilitic,  (588 
Syphiloma,  653 
Syphilis,  history  of,  20 
origin  of,  21 
virus  of,  419 
reinfection  with,  420 
incubation,  423 
evolution,  423 
sources  of  contagion,  429 
modes  of  contagion,  432 
second  period  of  incubation,  437 
the  nature  of,  439 
influence  of,  upon   the  constitution, 

496 
influence  of,  upon  diseases  in  general, 

498 
influence  of,  upon  traumatism,  500 
prognosis,  502 
expectant  treatment,  503 
irritability  of  skin  and  mucous  mem- 
branes, 507 
hereditary,  735 
relation  of,  to  scrofula,  rickets,  and 

phthisis,  736 
treatment,  787 
Arabian,  788 
hygienic,  788 
mercurial,  790 

fumigation,  795 
inunction,  798 
suppositories,  799 
hypodermic,  800 
efi"ects,  803 
duration,  808 

iodine  and  its  compounds,  810 
nitric  acid  and  gold,  817 
vegetable  decoctions,  817 
hydropathy,  818 
syphilization,  820 
Syphilides,  509 

classification,  510 

course  and  characteristics,  511 

influence  of  mercury,  513 

influence  of  intercurrent  diseases  on 

the  course  of,  513 
diagnosis,  516 

unusual  modes  of  evolution,  514 
localization  of,  514 
scales  and  crusts  of,  514 
erythematous,  516 
papular,  520 

miliary,  520 
lenticular,  522 
pustular,  531 
billions,  543 
tubercular,  544 
gumrnous,  549 
serpiginous,  555 
pigmentary,  558 
malignant  precocious,  559 
local  treatment  of,  563 
Syphilitic  bubo,  479 


Syphilitic  fever,  488 
Sypiiilitic  ulcers.  515 
Syphilization,  820 


rPANTURRI,  pigmentary  syphilide,  558 
I      Tardieu,  chancroids  of  anus  and  rec- 
tum, 381 
Tarnowski,  herpetic  urethritis,  47 
Tarsitis  syphilitica,  696 
Taylor,  Dr.  R.  W.,  chancroid  originating 
de  novo,  30 

operation  for  phimosis.  110 

transmission   of  syphilis  in  circum- 
cision, 432 

transmission  of  syphilis  in  vaccina- 
tion, 434 
T.ayuya,  818 

Teeth  in  hereditary  syphilis,  700 
Tendons,  affections  of,  668 
Testis,  inflammation  of,  130 

syphilis  of,  633 
Tetanus,  chronic  syphilitic,  (566 
Thin,  Dr.  Geo.,  microscopical  appearances 

of  hydroa,  816 
Thiry,  strapping  the  testicle  in  epididy- 
mitis, 150 

theory  of  gonorrhoea!  contagion,  45 
Thompson,  Sir  Henry,  causes  of  stricture, 
276 

caustics    in    treatment   of   stricture, 
312 

curves  of  urethra,  263 

number  of  strictures,  268 

over-distention,  297 

probe-pointed  catheter,  322 

seat  of  stiicture.  266 

treatment  of  bubo,  469 
Thoresen,  relation  of  syphilis  to  tubercu- 
losis of  the  lungs,  736 
Thymus  gland,  afiections  of,  in  hereditary 

syphilis,  763 
Thyroid  body  in  syphilis,  492 
Tillaux,  pelvic  fascia,  258 

perineal  fascit\;,  254 
Tilt,  results  of  vaginitis,  196 
Tinea,  circinata  inguinalis,  570 

versicolor,  573 
Tobacco,  in  gonorrhoea,  57 

in  syphilis,  601,  781 
Toes,  affections  of,  671 
Tongue,  affections  of,  592 
Tonics,  in  gonorrhoea,  5() 

in  treatment  of  syphilis,  788 
Torella,  induration  of  ciiancre,  451 
Trachea,  syphilis  of,  623 
Tracheotomy  in   laryngeal  syphilis,  618, 

626 
Treatment  of  phngedasna,  387 
Treatment  of  syphilis,  787 
Treatment  of  urethral  stricture,  294 

dilatation,  29  4 

continuous  dilatation,  297 

over-distention,  297 


834 


INDEX. 


Treatment  of  urethral  stricture — 

internal  incision,  298 

rupture,  '^O'.i 

caustics,  312 

external  uretlirotomy,  312 

Cock's  operation,  Slti 
Trichomonas  in  vaginitis,  189 
Tubercuhir  syphilide,  544 

diagnosis,  i')48 
Tumors  of  the  nervous  system,  653 
Tunnelled  sounds,  299 
Tyler  Smith,  treatment  of  gonorrhoea  in 

women,  201 


UMBILICAL  VEIN,  lesions  of,  in  hered- 
itary syphilis,  7<J5 
Unna,  pathology  of  chancre,  4tl4 
Ureters  in  stricture,  272 
Urethra,  250 

dimensions,  260 

moV)ility,  261 

curves,  262 
Urethral  discharge  in  syphilis,  44 
Urethral  fever,  320 
Urethral  instruments,  830 
Urethral  rheumatism,  230 
Urethrometers,  288 
Urethrotomes,  395 
Urinary   abscess  and   fistula,    treatment, 

329 
Urine,  retention  of,  321 
Uterus,  syphilis  of,  640 


VACCINO-SYPHILIS,  433 
Vagina,  syphilis  of,  640 
Vaginal  secretion  in  gonorrhoea,  189 
Vaginitis,  193 
Vajda,  tissue  metamorphosis  in  syphilis, 

490 
Van  Buren,  Prof.  W.  II.,  "tunnelled"  in- 
struments, 299 
Van  Buren  and  Keyes,  diagnosis  of  hy- 
drocele, 156 
iodide  of  potassium  by  rectal  injec- 
tion, 813 
syphilitic  aphasia,  660 
Van  Roosbroeck,  gonorrhoeal  ophthalmia, 

216 
Van  Swieten's  solution,  794 
Variola-form  syphilide,  534 
Varicocele,  164 

treatment,  165 
Vas  deferens,  affections  of,  638 
Vegetations,  242 
treatment,  244 

complicating  gonorrhoea  in   women, 
199 
Velpeau,  rectal  injections  of  copaiba,  68 

treatment  of  epididymitis,  146 
Venereal,  age  of  confusion  in,  23 

the  modern  school  of,  25 
Venereal  diseases,  history  of,  18 


Verneuil,  gummy  tumor  of  vas  deferens, 
639 
spasmodic  stricture,  267 
syphilis  and  traumatism,  500 
syphilis  of  rectum,  606 
Vertebrae,  syphilis  of,  644 
VesiculiB  seminales,  affections  of,  639 
Vesicular  syphilide,  534 
Vidal,  epiphysary  exostoses,  681 

puncture  in  treatment  of  swelled  tes- 
ticle, 152 
Viennois,  contagion  of  syphilis,  433 
Vierling,  syphilis  of  trachea,  623 

treatment,  624 
Virchow,  atropliy  of  bone,  683 
cicatrices  in  bone,  685 
classification  of  syphilitic  symptoms, 

428 
cj'to-blastomes,  441 
diagnosis  of  syphilitic  necrosis,  683 
hereditary    syphilis    of    supra-renal 

capsules,  761 
pathological  anatomy  of  chancre,  465 
syphilis  of  bronchi,  625 
syphilitic  affections  of  muscles,  664 
syphilis  of  nerves,  650 
affections  of  placenta,  781 
Virulent  bubo,  409 
Vitreous,  affections  of  the,  725 
Voillemier,  mode  of  introducing  a  cathe- 
ter, 291 
rupture  of  stricture,  311 
urethrotome,  306 
Volkmann,  hereditary  dactylitis,  771 
Von    Behrend,   influence    of  a    syphilitic 
foetus  upon  the  mother,  745 


WxVLDEYER,    hereditary    syphilis    of 
bones,  7t)7 
Warren,   Dr.   Ed.,  treatment  of   epididy- 
mitis, 147 
Wecker,  specific  iritis,  713 
AVegiier,  heieditary  syphilis  of  bones,  766 
hereditary  syphilis  of  pancreas,  760 
Weil,  syphilis  of  the  spleen,  (il2 
Weir,    Prof.    R.   F.,  use  of  endoscope  in 
stricture,  296 
urethrometer,  289 
sections  of  penis,  304 
operation  for  varicocele,  166 
W^eisflog,  hereditary  syphilis  of  thymus 
gland,  764 
hypodermic  use  of  the  nitrate  of  mer- 
cury, 802 
treatnietit  of  phagedaena,  ,388 
AVest,    .James  P.,    syphilitic    stricture  of 

oesophagus,  601 
Wever,  syphilis  of  tiie  spleen,  603 
Wheelhouse,  C.  U.,  operations  for  stric- 
ture, 315 
Whistler,  mucous  patches  of  the  larynx, 

620 
White  swelling,  syphilitic,  689 


INDEX. 


835 


Wiorgleswortb,  pxppriments  with  inocula- 
tion of  nonspecific  pus,  29 

Wilbouchewitcli,  effect  of  mercury,  803 
state  of  tlie  blood  in  sypliilis,  487 

Wilde,  Sir  William,  sypliilitic  meningitis, 
783 

Wilkinson's  ointment,  57 

Winckel,  lesions  of  tlie  umbilical  vein  in 
iiereditary  syphilis,  ~&i 


"Y^'ALE.    nervous  disturbnnce  caused  by 
1      phimosis,  etc.,  106 
Yeldham,  treatment  of  syphilis,  791 


ZAPPULA,  syphilis  of  rectum.  608 
Zeissl,  dingnosis  of  bubo,  406 
Zeiss!,  digit.tli--  in  gonorrhoea,  5-5 
epididymitis,  139 

expectiint  treatment  of  syphilis,  787 
inli:il:ition  of  ethereal  oil  of  copaiba, 

(1.5 
self  limitation  of  syphilis,  -50-3 
syphilis  of  rectum,  007 
treatment  of  bubo,  409 
urethral  chancroids,  376 
vegetations,  '242 
Zinsser,  Dr.  F.,  dualism,  17 


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fully  accord  toil  the  fir.-t  place,  for  nowhere  shall  i  oldest  periodicals  in  the  world — a  journal  which  has 
we  find  more  able  and  more  impartial  criticism,  and  |  an  unsullied  record.  —  Gross  s  History  of  American 


nowhere  such  a  repertory  of  able  original  articles. 
Indeed,  now  that  the  ''  British  and  Foreign  Medicn- 
Chirurgical  lieview"  has  terminated  its  career,  the 
American  Journal  stands  without  a  rival. — London 


31>'.d.  Literature,  IS76. 

It  is  universally  acknowledged  to  be  the  leading 
American  medical  journal,  and,  in  our  opinion,  is 


Mi-d    Times  ii'nd  <ifizttte,  yov.'2,i,\Sn.  j  second  to  none  in  the  language. —  Boston  Med.  and 

Surff.  Journal,  Oct.  IbTV. 


The  best  medical  journal  on  the  continent  — Bos 
ton  Med  and  Surg.  Journal,  April  17,  1879. 

The  present  nninber  of  the  American  Journal  is  an 


This  is  the  medical  journal  of  our  country  to  which 
the  American  physician  abroad  will  jjoint  with  the 


exceedingly  good  one,  and  gives  every  promise  of '  greatest  satisfaction,  as  retieoting  the  state  of  medical 
mainiaiuiiig  the  well  earnedieputation  lifthereview  jculture  in  his  country.  For  a  great  many  years  it 
Our  veneiable  contemporary  lias  our  best  wishes,  ]  ha-i  been  the  medium  through  which  our  ablest  writ- 
and  we  can  only  expre-s  the  hope  that  it  rnay  con- j  ers  have  made  known  their  discoveries  and  observa- 
tinue  its  work  with  as  much  vigor  and  excellence  for  I  tions  — Address  of  L.  P.  Yandell,  M. D.,  before  Inter- 
the  next  litty  years  as  it  has  exhibited  in  the  past.  \  national  Med.  Congress,  Sept.  1S76. 
—London  Lancet,  JJov.  21,  1677.  I 

And  that  it  was  specifically  included  in  the  award  of  a  medal  of  merit  to  the  Publisher 
in  the  Vienna  E.xhibition  in  1873. 

The  subscription  price  of  the  "American  Journal  of  the  Medical  Sciences"  has 
never  been  raised  during  its  long  career.  It  is  still  Five  Dollars  per  annum  ;  and 
when  paid  for  in  advance,  the  subscriber  receives  in  addition  the  "Medical  News  and 
Abstract,"  making  in  all  nearly  2000  large  octavo  pages  per  annum,  free  of  postage. 

II. 

THE  MEDICAL  NEWS  AND  ABSTRACT. 

Thirty-seven  years  ago  the  "Midical  News"  was  commenced  as  a  monthly  to 
coo\ey  to  the  subscribers  of  the  "American  Journal"  the  clinical  instruction  and 

*  Commaaications  are  invited  from  gentlemen  in  all  parts  of  the  country.  Elaborate  articles  inserted 
by  the  .Editor  are  paid  for  by  the  Publishers. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Am.  Journ.  lied.  Sci.).    3 

current  information  which  could  not  be  accommodated  in  the  Qaarterly.  It  con- 
sisted of  sixteen  paares  of  such  matter,  tojretber  with  eixtfen  more  known  as  tte 
Library  Department  and  devottd  to  the  publishing  of  books.  With  the  increased 
progress  of  Fcierce,  however,  this  vas  fcund  insufficient  and  some  years  since  an- 
other pe'^iod^cal.  known  as  the  "Mo^TflLY  Abstract,"  was  started,  and  was  fur- 
n'shtd  at  a  moderate  price  to  subscribers  to  the  "American  Journal."  These 
two  monthlies  will  hereafter  be  cor)solidat^d,  under  the  title  of  "The  Medical 
News  and  Abstract,"  and  will  be  furnished //ee  cf  charge  in  connection  with  the 
"Amerion  Journal." 

The  "News  AND  Abstract"  will  consist  of  64  pages  ncocthly.  in  a  neat  cover. 
It  will  conta^'n  a  CMNir-AL  Departme>t  in  which  will  be  continued  the  series  of 
Ortg'nal  American  Clinical  LECTURii's,  by  gentlemen  of  the  highest  reputation 
throughout  the  Unitfd  States,  together  wi  h  a  choice  selection  of  foreign  Lectures 
and  Hospi'al  Notes  and  Gleanings.  Then  will  follow  the  Momhly  Abstract,  syp- 
tematically  arranged  and  classified,  and  presenting  five  or  six  bur  died  articles  yearly  ; 
and  each  number  will  conclude  with  a  News  Department,  giving  current  profes- 
sional intelligence,  domestic  and  foreign,  the  whole  fully  indexed  at  the  c'ose  of 
each  volume,  rendering  it  of  permanent  value  for  re'eieice. 

As  stated  above,  the  subscription  price  to  the  "Ntws  and  Abstract"  will  be 
Two  Dollars  and  a  Half  per  annum,  invariably  in  advance,  at  which  rate  it  will  rank 
as  one  of  the  cheapest  medical  peri  dicals  in  the  country.  But  it  will  also  be  fur- 
nifhtd,  free  of  ell  charge,  in  commutation  with  the  "  Amer  can  Journal  op  Tiia 
Medical  Scijnces,"  to  all  who  remit  Five  Dollars  in  advance,  thus  giving  to  the 
subscriber,  for  that  very  moderate  sum,  a  complete  record  of  medical  progress 
throughout  the  world,  in  the  compass  of  about  two  thousand  large  octavo  pagos. 

In  this  effort  to  lurni|,sh  so  large  an  amount  of  practical  information  at  a  price  so 
unprecedntedly  low,  and  thus  place  it  within  the  reach  of  every  member  of  the 
profession,  the  publishers  confid  n.ly  anticipate  the  friendly  aid  of  all  who  feel  an 
interest  in  the  dissemination  of  sound  medical  literature.  They  trust,  e  pecially,  that 
the  subscribers  to  the  "Amkrican  Medical  Journal"  will  call  the  attention  of  their 
acquaintances  to  the  advantages  thus  offered,  and  that  they  will  be  sustained  in  the 
endeavor  to  permanently  establish  medical  periodical  literature  on  a  footing  of 
cheapness  never  heretofore  attempted. 

PREMIUM  POR  OBTAINING  NEW  SUBSOEIEERS  TO  THE  "JOURNAL." 
Any  gentleman  who  will  remit  the  amount  for  two  subscriptions  for  18c0,  one  of 
which  at  least  must  be  for  a  ve^v  fiubscrtber,  will  receive  as  a  premium,  free  by  mail,  a 
copy  of  any  one  of  the   following  rec  nt  works  : 

"Bapnes's  Manual  of  Midwifery"  (see  p.  24), 

"Tubuhy  Fox's  Epitome  of  Dis  ases  of  the  Sk  n,"  new  edition,  just  ready, 
(see  p.  18) 

"  Fotiieugill's  Antaoonism  of  Medicines"  (see  p.  It!), 

"IIoi^den's  Landmarks,  Mkuical  and  Suuoical"  (see  p.  6), 

"  Browne  on  the  Usk  of  the  Ophthalmoscope"  (seep.  2'.i), 

"  Flint's Kssays  on  Conskrvative  .Mkdicine"  (see  p.  Ijj, 

*' 8tur(iios's  Clinical  Mkdicink"  (see  p.  14), 

"Swayne's  Obstktrio  Aphorisms,"  new  edition  (sec  p.  21), 

"Tanner's  Clinical  Manual"  (see   p.  5), 

"West  on  Nervous  Disorders  of  Children'  (see  p.  20). 

%*  Gentlemen  desiring  to  avail  themselves  of  the  advantages  tlins  ofTered  will  do 
well  to  forward  their  subscriptions  at  an  early  day,  in  order  to  insure  the  receipt  of 
complete  sets  for  the  year  i860. 

1^"  The  sufest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn 
to  the  order  of  the  undersigned.  Where  these  are  not  accessible,  remittances  for  the 
"Journal"  may  be  made  at  the  risk  of  the  publishers,  by  forwarding  in  registered 
letters.     Address, 

Henry  C.  Lea's  Son  &  Co.,  Nos.  706  and  708  Sansom  St.,  Fhiia.,  Pa. 


Uenry  C.  Lea's  Son  &  Co.'s  Publications — {Dictionaries). 


jyUNGLISON  [ROBLEY),  M.D., 

'^'^  hnU.  Professor  of  Institutes  of  Medicinein  Jefferson  Medical  College,  Philadelphia. 

MEDICAL  LEXICON;   A  Dictionary  of  Medical  Science:  Con- 

t. lining  a  concise  eKplanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 

i'athology,  Hygiene,  Therapeutics.  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 

Jurisprudence,  and  Dentistry.     Notices  of  Climate  and  of  Mineral  Waters;  Formulae  for 

Officinal,  Empirical,  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  of 

the  Terms,  and  the  French  and  other  Synonymes  ;  so  as  to  constitute  a  French  as  well  as 

English  Medical  Lexicon.     A  New  Edition.     Thoroughlj'  Revised,  and  very  greatly  Mod. 

ified  and  Augmented.     By  Richard  J.  Dungli.son,  M.D.     In  one  very  large  and  hand- 

some  royaloctavo  volume  ot  over  1100  pages.     Cloth,  $6  50  ;  leather,  raised  bands,  $7  60. 

i^Jast  Issued.) 

The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 

dictionary  of  terms,  but  to  afford,  undereach,  a  condensed  view  of  its  various  medical  relations, 

aad  thus  to  render  the  work  an  ej)itome  of  the  existing  condition  of  medical  science.    Starting 

with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 

revisions,  to  augment  its  completeness  and  usefulness,  until  at  length  it  has  attained  the  position 

of  a  recognized  and  standard  authority  wherever  the  language  is  spoken. 

Special  pains  have  been  taken  in  the  preparation  of  the  present  edition  to  maintain  this  en  • 
viable  reputation.  During  the  tf  n  years  which  have  elapsed  since  the  List  revision,  the  additions 
to  the  nomenclature  of  the  medical  sciences  have  been  greater  than  perhaps  in  any  similar  period 
ofthe  past,  and  up  to  the  time  of  his  death  the  authorlabored  assiduously  to  incorporate  every- 
thing requiring  the  attention  of  the  student  or  practi  ioner.  Since  then,  the  editor  has  been 
equally  industrious,  so  that  the  additions  to  the  vocabulary  are  more  numerous  than  in  any  pre- 
vious revision.  Especial  attention  has  been  bestowed  on  the  accentuation,  which  will  be  found 
mnrked  on  every  word.  The  typigraphical  arrangement  has  been  much  improved,  rendering 
reference  much  more  easy,  and  every  care  has  been  taken  with  the  mechanical  execution.  The 
work  has  been  printed  on  new  type,  small  but  exceedingly  clear,  with  an  enlarged  page,  so  that 
the  additions  have  been  incorpot,ited  with  an  increase  of  but  little  over  a  hundred  pages,  and 
the  volume  now  contains  the  matter  of  at  least  four  ordinary  octavos. 


A  book  well  known  to  our  readers,  and  of  which 
every  American  ouirht  to  lie  proud.  When  the  learued 
author  of  the  work  pas.sed  away,  probably  all  of  us 
fe.ired  lest  the  bonk  should  uot  maintain  its  place 
in  the  advancins  science  who'e  terms  it  defines.  For- 
tunate.)', Ur.  Uichard  J.  DuuKlison,  having  assisted  his 
fiitheriii  the  revision  of  several  editions  of  the  work, 
and  havin;^been.  therefore,  trained  in  the  methods  and 
i  iibued  with  the  spirit  of  the  book,  has  been  able  to 
ejil  it.  not  in  the  patchwork  manner  so  dear  to  the 
heart  of  book  editors,  so  repulsive  to  the  taste  of  intel- 
li'rent  book  readers,  but  to  edit  it  as  a  work  ofthe  kind 
slTould  he  edited — to  carry  it  on  steadily,  without  jar 
or  interruption,  along  the  grooves  of  thouiiht  it  has 
travelled  during  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr  Dunglison  has  assumed  and  car- 
rie'l  through,  it  is  only  necessary  tn  stale  that  more 
than  si.\  thousand  new  subjects  have  been  added  in  the 
present  edition. — PInla.  Mrd.  Times,  Jan  3,  1874. 

About  the  first  book  purchased  by  the  medical  stu- 
.l-^nt  is  the  Medical  Dictionary.  The  lexicon  explana- 
to  -v  of  technical  terms  is  simply  a.sinfqva  non.  In  a 
6  ueace  so  exten-ive,  and  with  such  collaterals  as  meUi 
cine,  it  is  as  much  a  net^essity  also  to  the  practisine 
physician.  To  meet  the  wants  of  students  and  most 
pijysi  ians,  the  dictionary  must  be  condensed  while 
oinprehen.sive.  and  practical  while  perspicacious.  It 
was  bei-ause  Dunglison's  met  these  indications  that  it 
became  at  once  the  dictionary  of  general  use  wherever 
medicine  was  studied  in  the  KnL'lish  languaee.  In  no 
former  reusion  have  thealterations  and  additions  been 
80?reat.  Mjrethan  six  thousand  new subjci;ts and  terms 
have  been  added.  The  chief  terras  have  been  sot  in  black 
letter,  while  the  derivatives  follow  in  small  caps;  an 
airangement  which  greatly  facilitates  reference.     We 


may  safely  confirm  the  hope  ventured  by  the  editor 
"  that  the  work,  which  possesses  for  him  a  filial  as  well 
as  an  individual  interest,  will  be  found  worthy  a  con- 
tinnnuce  of  the  position  so  long  accorded  to  it  as  a 
itandard  authority." — Cincinnati  Clinic.  Jan.  10, 1874. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accaracyand  extent  of 
references. — London  Medical  Oazette 

As  a  Kta  ndaid  work  of  reference,  as  one  of  the  best, 
if  not  the  very  best,  medical  dictionary  in  the  Eng- 
lish language,  Dunglisou's  work  has  been  well  known 
for  about  forty  years,  and  needs  no  words  of  prai.-e 
on  our  part  to  recommend  it  to  the  members  of  the 
medical,  and,  likewise,  of  the  pharmaceutical  pro- 
fession. The  latter  esppcially  are  in  need  of  such  a 
work,  which  gives  leady  and  reliable  information 
on  thousands  of  subjects  and  terms  which  they  are 
liable  to  encounter  iu  pursuing  their  daily  avoca- 
tions, but  with  which  they  cannot  be  expected  to  be 
familiar.  The  work  before  us  fully  supplies  this 
want. — Am.  JuiLrn.  of  Phnrm.,  Feb.  1S74. 

A  valuable  dictionary  of  the  terms  employed  in 
medicine  and  tlie  allied  sciences,  and  of  the  rela- 
tions of  the  subjects  treated  under  each  head.  It  re- 
flects great  credit  on  its  able  American  author,  and 
well  deserves  the  authority  and  popularity  it  has 
obtained. — Briti.sh  Med.  Journ., Oct.  31,  1874. 

Few  works  of  this  class  exhibit  a  grander  monu- 
ment of  iiatient  research  and  of  sceniific  lore.  The 
extent  of  the  sale  of  this  lexicon  is  suflicient  to  tes- 
tify to  its  u.-e  ulness,  and  to  the  great  service  con- 
ferred by  Dr.  K  diley  Dunglison  on  the  profession, 
and  indeed  on  others,  by  its  issue. — London  Lancet , 
May  13   1^75. 


a 


ODLYN  [RICHARD  D.),  M.D 

A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.     Revised,  with  numerous  additions,  by  Isaac  Havs, 
M.  D.,  Editor  ol  the  "  American  Journal  of  the  Medical  Sciences."     In  one  Itirge  royal 
12mo.  volume  of  over  500  double-columned  pages  ;  cloth,  $1  60;  leather,  $2  00 
It  is  th-  be-t  bouk  of  difluitions  we  have,  and  ought  always  to  be  upon  the  student's  VAble.— Southern 
Med.  and  hurg.  Joxi-rnul. 


I 


)0D  WELL  (G.  F),  F.R.A.S..  §r. 

A  DICTIONARY  OF  SCIENCE:  Comprising  Astronomy,  Chom- 

istry,  Dynamir-E,  Electricity,  Heat,  Hydrodyn.imics,  Hydrostatics,  Light,  Mtignetism, 
Mechanics,  Meteorology,  Pneumatics,  Sound,  and  Statics.  Preceded  by  an  Essay  on  the 
History  of  the  Physical  Sciences.  In  one  handsome  octavo  volume  of  694  pages,  and 
many  illustrations:  cloth,  $6. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Manuals'). 


A  CENTURY  OF  AMERICAN MEDICiyE.  1776-1876.  By  Doctors  E.  H. 
-^^  Clarke,  H.  J.  Bigelow,  S.  D.  Gross,  T.  G.  Thomas,  and  J.  S.  Billings.  Inone  very  hand- 
some 12mo.  volume  of  about  350  pages  :  cloth,  $2  25.      (Just  Ready.) 

This  work  appeared  in  the  pages  of  the  American  Journal  of  the  Medical  Sciencesduring  the 
year  1876.  As  a  detailed  account  of  the  development  of  medical  science  in  America,  by  gentle- 
men of  the  highest  authority  in  their  respective  departments,  the  profession  will  no  doubt  wel- 
coine  it  in  a  form  adapted  for  preservation  and  reference. 


J\JEILL  {JOHN),  M.D.,  and     aMITH  {FRANCIS  G.),  M.D., 

Prof,  of  the  InHitutesof  Medicine  in  the  Univ.  of  Penna 

AX    AJ^ALYTICAL    COMPENDIUM   OF   THE    VARIOUS 

BRANCHES  OF  MEDICAL  SCIENCE  ;  for  the  Use  and  Examination  of  Students.  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  12m(.. 
volume,  of  about  one  thousand  pages,  with  374  wood-cuts,  cloth,  $4  ;  strongly  bound  in 
leather,  with  raised  bands,  $4  75. 


TJARTSHORNE  {HENRY),  31. D., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A    CONSPECTUS    OF   THE   MEDICAL   SCIENCES;   containing 

Handbooks  on   Anatomy,  Physiology,  Chemistry,  Materia   Medica,   Practical  Medicin?, 
Surgery,  and  Obstetrics.   Second  Edition,  thoroughly  revised  and  improved.  In  one  lar^e 
royal  12mo.  volume  of  more  than  1000  closely  printed  pages,  with  477  illustrations  on 
wood.     Cloth,  $4  25  ;  leather,  S5  00.     {Lately  Issued.) 
We  cau  say  with  the  strictest  truth  that  it  is  the 
best  work  of  the  kind  with  which  we  artacquaiQled. 
It  embodies  in  a  condensed  form  all  recent  contribu- 
tions to  practical  medicine,  and  is  therefore  useful 
to  every  busy  practitioner  throughout  onr  country, 
besides  being  admirably  adapted  to  the  use  of  stu- 
dents of  medicine.    The  book  is  faithfully  and  ably 
executed. — Charleston  Med.  Jotirn.,  April,  1875. 


The  work  is  intended  as  an   aid  to  the  medical 


worthy.  If  students  must  have  a  conspectus,  they 
will  be  wise  to  procure  that  of  Dr.  Hartshome.— 
Detroit  Rev.  of  Med  and  Pliarm.,  Aug.  1S74. 

The  work  before  us,  however,  has  many  redeem- 
ing features  not  possessed  by  others,  and  is  the  best 
wehaveseen.  Dr.  Hartshorne  exhibits  much  skill  in 
condensation  It  is  well  adapted  to  the  pJiysician  in 
active  practice,  who  can  give  butlimiied  time  to  the 
familiarizing  of  himself  with  the  important  chances 
stuient,  and  as  such  appears  to  admirably  fulfil  its  i  which  have  been  made  since  he  attended  lectures 
object  by  itsexcelleut  arrangement,  the  full  compi-  i  The  manual  of  physiology  has  also  been  improved 
lation  9f  facts,  the  perspicuity  and  terseness  of  Ian-  !  and  gives  the  most  comprehensive  view  of  the  late  t 

guage,  and  the  clear  and  instructive  illustrations       '  ....  

in  some  parts  of  the  work — American  Journ.  of 
Pharmacy,  Philadelphia,  July,  187-1. 

The  volume  will  be  found  useful,  not  only  to  stu- 
dents, bnt  to  many  others  whomay  desire  torefresh 
their  memories  with  the  smallest  possible  expendi- 
ture of  time. — N.  Y.  Med.  Journal,  Sept.  1874. 

The  student  will  find  this  the  most  convenient  and 

useful  book  of  the  kind  on  which  he  can  lay  his 

hand. — Pacific  Med.  and  Surg.  Journ.,  Aug.  iS74. 

This  is  the  best  bookofita  kind  that  we  have  ever 


advances  in  the  science  possible  in  the  space  devoted 
to  the  subject.  The  mechanical  ex3cution  of  the 
book  leaves  nothing  to  be  wished  iov.— Peninsular 
Journal  of  Medicine,  Sept.  1874. 

After  carefully  looking  through  this  conspectus, 
we  are  constrained  to  say  that  it  is  the  most  com- 
plete work,  especially  in  its  illustrations,  of  its  kind 
that  we  have  seen. — Cincinnati  Lancet,  Sept.  1874. 

The  favor  with  which  the  first  edition  of  this 
Compendinm  was  received,  was  an  evidence  of  its 
various  excellences.     The  present  edition  bears  evi- 


exaraiued.  It  is  an  honest,  accurate,  and  concise  i  dence  of  a  careful  and  thorough  revision.  Dr.  Harts 
compeud  of  medical  sciences,  as  fairly  as  possible  I  home  possesses  a  liappy  faculty  of  seizing  upon  the 
representing  their  present  condition.     The  changes  I  salientpoints  of  each  subject,  and  of  presenting  them 

and  the  additions  liave  been  so  judicious  and  tho-  I  in  a  concise  and  yet  persoicuous  manner. Leavtn- 

rough  as  to  render  it, so  far  as  it  goes,  entirely  trust-  j  worth  Med.  Heraid,  Oct.  1S74 


rUDLOW  {J.L.),  M.D. 
A   MANUAL   OF  EXAMINATIONS  upon  Anatomy,  Physiology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry.  Pharmacy,  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustration.s.  In  one  handsome  royal 
12mo.  volume  of  816  large  pages,  cloth,  $3  25  ;  leather,  $3  75. 
The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit- 
able for  the  ofifice  exatuination  of  students,  and  for  those  preparing  for  graduation. 


/TANNER  {THOMAS  HA  WKES),  M.D.,  Sfc. 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAG- 

NOSIS.     Third  American  from  the  Second  London  Edition.    Revised  and  Enlarged  by 
Tilbury  Fox,  M.  D.,  Physician  to  the  Skin  Department  in  University  College  Hospital, 
Ac.   In  one  neat  volume  small  ]2mo.,  of  about  375  pages,  cloth,  $1  50. 
*^*  On  page  3,  it  will  be  seen  that  this  work  is  offered  a.s  a  premium  for  procuring  new 
subscribers  to  the  "American  Journal  of  tue  Mkdical  Sciences.'' 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Anatomy). 


riRAY  [HENRY),  F.R.S., 

^^  Lecturer  011  Anatomy  at  St.  George's  Hospital,  London. 

ANATOMY,  DESCRIPTIVE    AND  SURGICAL.     The  Drawings  by 

H.  V.  Carter,  M.D.,  and  Dr.  Westmacott.    The  Dissections  jointly  hy  the  Author  and 
Dr.  Carter.     With  an    Introduction    on    General    Anatomy  and  Development  by  T. 
Holmes,  M.A.,  Surgeon  to  St.   George'.';  Ho.^piial.     A  new  American,  from  the  eighth 
enlarges  and  improved  London  edition.     To  which  is  added  "  LAiNDMAUKS,  Medical  and 
Surgical,"  by  Luther  Hold  en,  F.K.C.S.,  author  of  "  Human  Osteology,"  "A  Manual 
of  Dissections,"   etc.     In  one  m.Tgnificent  imperial   octavo  volume  of  083   pages,  with 
522  large  and  elaborate  engravings  on   wood.     Cloth,  $6;  leather,  raised  bands,  $7. 
{Just  liiady.) 
The  author  has  endeavored  in  this  work  to  cover  a  more  extended  range  of  subjects  than  isouf- 
tomary  in  the  ordinary  te.xt-books,  by  giving  not  only  the  details  necessary  for  the  student,  btt 
also  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thus  rendering  it  both 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  en- 
gravings form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
fiwuresof  reference,  with  descriptions  at  the  foot.  They  thus  form  a  complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room  ;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
essential  use  to  all  physicians  who  receive  students  in  their  ofiBces,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Since  the  appearance  of  the  last  American  Edition,  the  work  has  received  three  revisions  at  the 
hands  of  its  accomplished  editor,  Mr.  Holmes,  who  has  sedulously  introduced  whatever  has  seemed 
requisite  to  maintain  its  reputiition  as  acomplete  and  authnritp'ive  standard  text-book  and  work 
of  reference.  Still  further  to  increase  its  usefulness,  there  tms  been  appended  to  it  the  recent 
work  by  the  distinguished  anatomist,  Mr.  Luther  Holden — "Landmarks,  Medical  and  Surgicnl" 
which  gives  in  a  clear,  condensed,  and  systematic  way,  all  the  information  by  which  the  prac- 
titioner can  determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work,  it  is  believed,  will  furnish  all  the  assistance  that  can  be  rendered  by  type  and 
illustration  in  anatomical  study.  No  pains  have  been  spared  in  the  typographical  execution  of 
the  volume,  which  will  be  found  in  all  respects  superior  to  former  issues.  Notwithstanding  the 
increase  of  size,  amounting  to  over  100  page?  and  57  illustrations,  it  will  be  kept,  as  heretofore, 
at  a  price  rendering  it  one  of  the  cheapest  works  ever  offered  to  the  American  profession. 

The  recent  work   of  Mr.  Holden,  which  was  no-  1  to   consult   his  books   on   anatomy.     The   work   is 
ticed  by  us  on  p.  i>i  of  this  volnme,  has  been  added     simply  indinpen-sabie,  especially  this  present  Amer- 
as  an  appendix,  so  that,  altogether,  this  is  the  mot  t    i can  edition. 
Dractical  and  complete  anatomical  treatise  available  ' 


■  Va.  3Ied.  Monthly,  Sept.  187F. 


to  American  students  and  phy^icianB.  The  former 
finds  in  it  the  nece.ssary  guide  in  making  dissec- 
tions; a  very  comprehensive  chapter  on  minute 
anatomy;  and  about  all  that  can  be  taught  liim  on 
general  and  special  anatomy;  while  the  latter,  in 
its  treatment  of  each  region  from  a  surgical  point  of 
view,  and  in  the  valuable  edition  of  Mr  Holden, 
will  find  all  that  will  be  essential  to  him  in  his 
practice  —A'ew  Remedies,  Aug.  1S7S. 

This  work  is  as  near  perfection  as  one  could  pos- 
sibly or  reasonably  expect  any  book  intended  as  a 
text-book  or  a  general  reference  book  on  anatomy 
to  be.  The  American  publisher  deserves  the  thanks 
of  lh«  profession  for  appending  the  recent  work  of 
Mr.  Holden,  "  Landmai  Ic.'i,  Medical  and  Sargica.l," 
which  has  already  been  commended  as  a  separate 
book.  The  latter  work— treating  of  topographical 
anatomy— has  become  an  essentia!  to  the  library  of 
every  intelligent  practitioner.  We  know  of  no 
book  that  can  take  its  place,  written  as  it  is  by  a 
most  distinguished  anatomist.  It  would  be  simply 
a  waste  of  words  to  say  any  thing  further  in  praise 
of  Orgy's  Anatomy,  the  text-book  in  almost  every 
medical  college  in'this  country,  and  the  daily  refer 
ence  book  of  every  practitioner  who  has  occasion 


The  addition  of  the  recent  work  of  Mr.  Holden, 
as  an  appendix,  renders  this  the  most  practical  and 
complete  treatise  available  to  AmKricau  students, 
who  find  in  it  a  comprehensive  chapter  on  minute 
anatomy,  about  all  that  can  be  taught  on  general 
and  special  anatomy,  while  its  treatment  of  each 
region,  from  a  surgical  point  of  vie^,  in  the  valu- 
able section  by  .Mr.  Holden, is  all  that  will  be  essen- 
tial to  them  in  practice. — Oliio  Medical  Recorder, 
Aug   1S78. 

It  is  diflScuIt  to  speak  In  moderate  terms  of  this 
new  edition  of  "Gray."  It  seems  to  be  as  nearly 
perfect  as  it  is  possible  to  make  a  book  devoted  to 
any  branch  of  medical  science.  The  labors  of  the 
eminent  men  who  have  successively  revised  the 
eight  editions  through  which  it  lias  passed,  would 
seem  to  leave  notliing  for  future  editors  to  do.  The 
addition  of  Holden's  "  Landmarks"  will  make  it  as 
indispensable  to  the  practitioner  of  medicine  and 
surgery  as  it  has  been  heretofore  to  the  student.  As 
regardt  completeness,  ease  of  reference,  utility, 
beauty,  and  cheapness,  it  has  no  rival.  No  stu- 
dent should  enter  a  medical  school  without  it  ;  no 
physician  can  afford  to  have  it  absent  from  his 
library. — Ht.  Louis  Clin.  Record,  Sept.  1878. 


ff 


H 


Also  for  sale  separate — 
'OLD EN  {LUTHER),  F.R.C.S., 

Surgeon  to  St.  Bartholomew's  and  the  Foundling  Ho.ipitrils. 

LANDMARKS,  MEDICAL  AND  SURGICAL.   From  the  2(1  London 

Ed.   In  one  handsome  volume,  royal  12mo.,  of  128  pages  :  cloth,  88  cents.    {Now  Ready.) 
EATE  [CHRISTOPHER],  P.R.C.S., 

Teacher  of  0[jerative  Surgery  in  Univer.nty  College,  London. 

PRACTICAL  ANATOMY:    A  Manual  of  Dissections.     From  the 

Second  revised  and  improved  London  edition.  Edited,  with  additions,  by  W.  W.  Keen, 
M .  D. ,  Lecturer  on  Pathological  Anatomy  in  the  Jefferson  Medical  College;  Philadelphia. 
In  one  handsome  royal  12mo.volume  of  578  pages,  with  247iHustration8.  Cloth,  $3  60  ; 
leather,  $4  00. 


Henry  C  Lea's  Son  &  Co.'s  Publications — {Anatomy).  T 

A  LLEN  {HARRISON).  M.D. 

■^^  PriifesKor  of  Physiology  in  the  Univ.  of  Pa. 

A  SYSTEM  OF  HUMAN  ANATOMY:  INCLUDING  ITS  MKDICAL 

and  Surgical  Relations.  For  the  Use  of  Practitioners  and  Students  of  Medicine.   With  an 
Introductory  Chapter  on  Histology.  By  E.  0.  Shakespeare,  M  D  ,  Ophthalmologist  to  the 
Phila.  Hosp.    In  one  large  and  handsome  quarto  volume,  with  several  hundred  original 
illustrations  on  lithographic  plates,  and  cuiuerous  wood-cuts  in  the  text.      (Preparing.) 
In  this  elaborate  work,  which  has  been  in  active  preparation  for  several  years,  the  author  has 
sought  to  give,  not  only  the  details  of  descriptive  anatomy  in  a  clearnnd  condensed  form,  but  also 
the  practical  applications  of  the  science  to  medicine  and  surgery.  The  work  thus  has  claims  upon 
the  att;?ntion  of  the  general  pr;i.ctitioner,  as  well  as  of  the  student,  enabling  him  not  only  to  re- 
fresh his  recollections  of  the  disseciing  rr.oin,  but  also  to  recognize  thesignificance  of  all  varia- 
tions from  normal  conditions.     The  marked  utility  of  the  object  thus  sought  by  the  author  is 
self  evident,  and  his  long  experience  and  assiduous  devotion  to  its  thorough  development  are  a 
sufficient  guarantee  of  the  manner  in  which  his  aims  have  been  carried  out.   No  pains  have  been 
spared  with  the  illustrations.  Those  of  normal  anatomy  are  from  original  disseeti  jns,  drawn  on 
stone  by  Mr.  Hermann  Faber,  with  the  name  of  every  part  clearly  engr.-ived  upon  the  ficrure, 
after  the  manner  of  "  Holden"  and  "  Gray, "  and  in  every  typographical  detail   it  will  be  the 
effort  of  the  publisher  to  render  the  volume  worthy  of  the  very  distinguished  position  which  is 
anticipated  for  it. 

fpiLIS  [GEORGE   VINER). 

-*--•  Eraerilwt  I'roftsnor  of  Anatomy  in  University  College,  London. 

DEMONSTRATIONS  OF  ANATOMY;  Being  a  Guide  to  the  Know- 

ledge  of  the  Human  Body  by  Dissection.  By  George  Viner  Ellis,  Emeritus  Professor 
of   Anatomy  in    University  College,   London.     From   the   Eighth  and  Revised  London 
Edition.     In  one  very  handsome  octavo  volume  of  over  700  pages,  with  256  illustrations. 
Cloth,  S4.25  ;  leather,  $5.25.      (Jvst  Ready.) 
This  work  has  long  been  known  in  England  as  the  leading  authority  on  practical  anatomy, 
and  the  favorite  guide  in  the  dissecting-room,  as  is  attested  by  the  numerous  editions  thrpu"-h 
which  it  has  passed.     In  the  last  revision,  which  has  just  appeared  in  London,  the  accomplished 
author  has  sought  to  bring  it  on  a  level  with  the  most  recent  advances  of  science  by  makino-  the 
necessary  changes  in  his  account  of  the  microscopic  structure  of  the  diflerent  organs,  as  devel- 
oped by  the  latest  researches  in  textural  anatomy. 

Ellih'.s  DeraoQStrations  is  the  favorite  text-book    its  leadership  over  the  Eugiish  manuals  upon  dis- 
of  the   English    student   of   anatomy.     In  pas.-^ing    secting. — Phila.  Med.  ru/it*,  May  24,  1S79. 
throujjh  eight  editions  it  has  been  i-o  revii-ed  and  , 

adapted  to  the  needs  of  the  student  hat  it  would  A"*  *  dissector,  or  a  work  to  have  in  hand  and 
seem  thai  it  had  almost  reached  perfection  in  ihii  studied  while  one  is  engaged  in  dissecting,  we  re 
special  line.  The  desciiptions  are  clear,  and  the  ?*"!  "  ^*'  t''^  ^<^'T  '"'*t  '^"^■'k  extant,  which  is  cer- 
methods  of  pursuing  anatomical  inve.-tigations  are  tainly  saying  a  veiy  great  deal.  As  a  textbook  to 
given  with  such  detail  that  the  book  is  honestly  ^^  studied  in  the  dissecting-room,  it  is  superior  to 
entitled  to  its  name.— ,S<.  Louis  Clinical  Record,    any  of  the  works  upon  anatomy.— Cinct?i7ia«i  Med. 


June,  1S79. 

The  success  of  this  old  manual  seems  to  he  as  well 
deserved  in  the  present  as  in  the  pa^t  volumes. 
The  book  oeems  destined  to  maintain  yet  for  jears 


KeWf,  May  2t,  1879. 

We   most  unreservedly  recommend   it  to   every 

practitioner  of  medicine  who  can  possibly  get  it. 

Vo.  Med.  Monthly,  June,  1S79. 


yUILSON  (ERASMUS),  F.R.S. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.  Edited 

by  W.  H.  GoERECHT,  M.D  ,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  Col- 
lege of  Ohio.  Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.  In 
one  large  and  handsome  octavo  volume,  of  over  tiOO  large  pages  ;  cloth,  $4  ;  leather,  $6. 

^MITH  [HENRY H.),  M.D.,         and  TJORNER  [  WILLIAM  E.),M.D., 

Prof,  of  Surgery  in  the  Univ.  ofPenna.,  Ac.  Late  Prof,  of  Anatomy  i?i  the  Univ.  of  Per.na. 

AN    ANATOMICAL   ATLAS  ;    illustrative   of  the  Structure  of  the 

Human  Body.  In  one  volume,  large  imperial  octavo,  cloth,  with  about  six  hundred  and 
fifty  beautiful  figures.     $4  50. 


s 


CHAFER  [EDWARD  ALBERT),  M.D., 

A.i8i!itavt  Profemor  of  Pliyxiology  in  Vniver.\ily  Coihge,  London. 

A  COURSE  OF  PRACTICAL  HISTOLOGY:  Beiii-  an  Introduction  to 

the  Use  of  the  Microscope,     [n  one  handsome  royal  12uio.  volume  of  304  pages,  with 
numerous  illustrations:  cloth,  $2  00.     {Just  Issued.) 


HORNER'S  SPECIAL  ANATOMY  AND  HISTOL-  BELLAMYS  STUDENT'S  GUIDE  TO  SURfilCAL 
OGY.  Eighth  edition,  exteUHively  revised  and  ^  ANaI'OMY:  A  Text  book  for  Stndf-nts  prerarirg 
modified  In  2  vols.  8vo.,  of  over  1000  pages,  for  their  I'afs  Examii  ation.  With  eDgiarlugs  ou 
with  . '520  wood  cuts  :  cloth.  *fi  no  wood      In    one   handsome   royal   12rao.  volume 

SHARPEY    AND    QUAIN'S    HUMAN    ANATOMY.        Cloth. !»22j. 

Keri-sed,  by  Joskph  Lkiot,  M.D.,  Prof  of  Anat.  !  CLELAN  D'S  DIRECTOUY  FOR  THE  DISSECTION 
in  Uoiv.  ot  Penn.  In  two  octavo  vols,  of  about  !  OF  THE  HU.MA.N  U(Jl)V.  Id  one  small  volume 
laOO  pages,  with  jll  illustrations.    Cloth,  $0  00.  I      royal  l2mo.  of  182  pagen'  oloih  ♦!  25. 


Heney  C.  Lea's  Son  &  Co.'s  Publications — {Physiology). 


(CARPENTER  (  WILLIAM  B.),  M.D.,  F.R.S.,  F.G.S.,  F.L.S., 

'-^  Regifitrar  to  University  of  London,  etc. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  Edited  by  Henry  Power, 

M.B.  Lond.,  F.R.C.S.,  Examiner  in  Natural  Sciences,  University  of  Oxford.     Anew 
American  from  the  Eighth  Revised  and  Enlarged  English  Edition,  with  Notes  and  Addi- 
tions, by  Francis  6.  Smith,  M.D.,  Professor  of  the  Institutes  of  Medicine  in  the  Univer- 
sity of  Pennsylvania,  etc.  In  one  very  large  and  handsome  octavo  volume,  of  1083  pages, 
with  two  plates  and  .3  73  engravings  on  wood;  cloth,  $6  50  ;  leather,  $6  50.    (Jitst  Iss7ied.) 
Thegreatwork,  the  crowning  labor  of  the  distinguished  author,  and  through  which  so  many 
generations  of  students  have  acquired  their  knowledge  of  Physiology, has  been  almost  meta- 
morphosed in  the  effort  to  a(?apt  it  thoroughly  to  the  requirements  of  modern  science.    Since 
the  appearance  of  the  last  American  edition,  it  has  had  several  revisions  at  the  experienced 
hand  ol  Mr.  Power,  who  has  modified  and  enlarged  it  so  as  to  introduce  all  that  is  important 
in  the  investigations  and  discoveries  of  England,  France,  and  Germany,  resulting  in  an  enlarge- 
ment of  about  one-fourth  in  the  text.   The  series  of  illustrations  has  undergone  a  like  revision, 
a  large  proportion  of  the  former  ones  having  been  rejected,  and  the  total  number  increased 
to  nearly  four  hundred.     The  thorough  revision  which  the  work  has  so  recently  received  in 
England,  has  rendered  unnecessary  any  elaborate  additions  in  this  country,  but  the  American 
Editor,  Professor  Smith,  has  introduced  such  matters  as  his  long  experience  has  shown  him  to 
be  requisite  for  the  student.   Every  care  has  been  taken  with  the  typographical  execution,  and 
the  work  is  presented,  with  its  thousand  closely,  but  clearly  printed  pages,  as  emphatically  the 
text-book  for  the  student  and  practitioner  of  medicine — the  one  in  which,  as  heretofore,  especial 
care  is  directed  to  show  the  applications  of  physiology  in  the  various  practical  branches  of 
medical  science.     Notwithstanding  its  very  great  enlargement,  the  price  has  not  been  in- 
creased, rendering  this  one  of  the  cheapest  works  now  before  the  profession. 


We  have  been  agreeably  surprised  to  find  the  vol- 
ume 80  complete  in  regard  to  the  structure  and  func- 
tions of  the  nervous  system  in  all  its  relations,  a 
subject  that,  in  many  respects,  is  one  oft  he  most  diffi- 
cult of  all,  in  the  whole  range  of  physiology,  upon 
which  to  produce  a  full  and  satisfactory  treatise  of 
the  class  to  which  the  one  before  us  belongs.  The 
additions  by  the  American  editor  give  to  the  work  as 
it  is  a  considerable  value  beyond  that  of  the  last 
English  edition.  In  conclusion,  we  can  give  our  cor- 
dial recommendation  to  the  work  as  it  now  appears. 
The  editors  have,  with  their  additions  to  the  only 
work  on  physiology  in  our  language  that,  in  the  full- 
est sens-e  of  the  word,  is  the  production  of  a  philoso- 


new  a  year  or  two  ago,  looks  now  as  if  it  had  been  a 
received  and  established  fact  for  years.  In  this  ency- 
clopfedic  way  it  is  unrivalled.  Here,  as  it  seems  to 
us,  is  the  great  value  of  the  book;  one  is  safe  in  sending 
a  student  to  it  for  information  on  almost  any  given 
subject,  perfectly  certain  of  the  fulness  of  information 
it  will  convey,  and  well  satisfied  of  the  accuracy  with 
which  it  will  there  be  found  stated. — London  Med. 
Times  and  Gazette,  Feb.  17, 1877. 

The  merits  of  "  Carpenter's  Physiology"  are  so  widely 
known  ami  appreciated  that  we  need  only  allude  brieiiy 
to  the  fact  that  in  the  late.'it  edition  will  be  found  a  com- 
prehen,«ive  embodiment  of  the  results  of  recent  physio- 


.         .  <•   ,,       logical  investigation.  Care  ha.s  been  taken  to  preserve 

pher  as  well  as  a  physiologist,  brought  It  up  as  tuUy  j  the  practical  char.acter  of  the  original  work.    In  fact 
as  could  be  expected,  if  not  desired,  to  the  standara    jijg  entire  work  has  been  brought  up  to  date,  and  bears 
of  our  knowledge  of  its  subject  at  the  present  day. 
It  will  deservedly  maintain  the  place  it  has  always 
had  in  the  favor  of  the  medical  profession. — Journ. 
of  Nervous  and  Mental  Disease,  April,  1S77. 

Such  enormous  advances  have  recently  been  made  in 
our  physiological  knowledge,  that  what  was  perfectly 


rought  up  t 

evidence  of  the  amount  of  labor  that  has  been  be.iitowed 
upon  it  by  its  distinguished  editor,  Mr.  Henry  Power. 
The  American  editor  has  made  the  latest  additions,  in 
order  fully  to  cover  the  time  that  has  elapsed  since  the 
last  English  edition. — N.  Y.  Med.  Journal, l&u.lill . 


-prOSTER  [MICHAEL],  M.D.,  F.R.S., 

J-  Prof,  of  Vhy sudor) y  in  Cambridge  Univ.,  England. 

TEXT-BOOK  OF  PHYSIOLOGY.     A  new  American,  from  the  third 

English   edition.     Edited  with  notes  and   additions  by  Edward  T.  Reichert,  M.D., 
Demonstrator  of  Experimental  Therapeutics  in  Univ.  of  Penna.    In  one  handsome  royal 
12mo.  volume,  with  over  250  illustrations.      {Nearly  Ready.) 
The  excellence  of  Mr.   Foster's  work  as   an  exposition  of  functional  physiology  has  long 
been   recognized,  while  for  the  purposes  of  the  student  it   has  been   somewhat  deficient  as  re- 
spects the  details  of  structure  so  necessary  to  render  intelligible  the  views  and  theories  of  the 
science.     These  it  has  been  the  effort  of  the  editor  to  add  in  as  concise  a  manner  as  possible, 
and  in  aid  of  this  he  has  freely  introduced   illustrations  from  recognized   authorities.     In  this 
improved  form  it  is  therefore  hoped  that  the  work  may  prove  more  than  ever  acceptable  to  the 
student  as  a  clear  and  comprehensive  text-book,  presenting  the  science  in  its  latest  development. 
On  the  whole  the  book  can  be  called  the  standard     the   subject,  can   little  appreciate  what    advances 
work  in  the  English  language,  while  it  has  none  ^u-  :  have  been  made,  and  can  do  nothing  better  t  ban  to 
perior  in  any  other  tongue.     It  i.-^,  perhaps,  the  only    give  Ur.  Fusier's  work  some  careful  reading. — New 
work  in  our'language  which  represents  physiolosy    Remedies,  Jan.  ISSO. 

fully  as  an  experimental  science.  Its  completeness  ,  ipi,g  author  of  this  book  is  too  well  known  to 
isadmirable.  Theanxious  student  can  find  not  only  physiologists  to  reciuire  an  introduction.  His  con- 
the  actual  facts  of  the  science,  but  also  the  mode  in  tribution's  to  this  branch  of  science  have  secured  for 
which  they  were  obtained.  The  author  proves  to  the  j,i„,  lasting  fame.  As  an  advanced  thinker  and 
student  not  only  a  compiler  but  a  judicious  critic—  .^riter  his  views  and  teaching  are  regarded  as  the 
Journ.  of  Nervous  and  Mental  Diseases,  Jan,  1S80.  jiighest  authority,  and  maybe  accepted  as  the  latect 
The  work,  since  its  first  appearance,  has  con-  '  ""'come  of  physiological  research  and  study.- 
tinued  to  be  oneof  the  most  satisfactory  text-books  j  Maryland  Med.  Journal,  Feb.  ItbJ. 
on  the  subject  that  we  have  met  with,  and  is  in  i  An  elaborate  review  at  present  is  not  required; 
many  respects  peculiarly  adapted  to  the  use  of  it  is  only  necessary  to  say  that  it  is  the  be.-t  book 
praccitioners.  Those  whose  knowledge  of  the  func-  \  of  its  immediate  scope  in  any  of  the  three  1 1  nguages, 
tions  of  organs  was  chiefly  acquired  a  decade  ago,  ;  so  far,  at  least,  as  our  knowledge  goes. — Philuda, 
and  who  have  not  since  been  diligent  students  of  i  Med.  Times,  Jan.  3,  1S80. 

HARTSHOKNE'S  HANDBOOK  OF  ANATOMY  AND  and  Additions,  by  J.  Cheston  Morrt-s,  M.D.   With 

PHYSIOLOGY.    Second  edition,  revised.    In  one  illustrations  on  wood.     la  one  octavo  volume  of 

royal   12mo.    vol.,   with   220   woodcuts  ;    cloth,  3.36  pages.     Cloih,  .^'i  25. 

$1  7.5.  LEHMANN'S  PHYSIOLOGICAL  CHEMISTRY.  Com- 

LEHMANK'S  MANUAL  OF  CHEMICAL  PHYSIOL-  plete  in  two  laige  octavo  volumes  of  1200  pages, 

OGY.     Translated  from  the  German,  with  Notes  with  200  illustrations;  cloth,  !ji6. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Physiology,  Chemistry).   9 
fk ALTON  {J.  C),  M.D., 

•*-^  Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York,  Ac. 

A  TREATISE  ON  HUMAX  PHYSIOLOGY.    Designed  for  the  use 

of  Students  and  Practitioners  of  Medicine.  Sixth  edition,  thoroughly  revised  and  enlarged, 
■with  three  hundred  and  si-^cteen  illustrations  on  wood.    In  one  very  beautiful  octavo  vol- 
ume, of  over  800  pages.     Cloth,  $5  50  ;  leather,  $6  50.     iJust  Issued.) 
During  the  past  few  year.*  several  new  works  on  phy-(      This  popular  text-book  on  physiology  comes  to  us  in 


Biology,  and  new  editions  of  old  works,  have  appeared, 
competing  for  the  favor  of  the  medical  student,  but 
none  will  rival  this  new  edition  of  Dalton.  As  now  en- 
larged, it  will  be  found  also  to  be,  in  general,  a  satisfac- 
tory work  of  reference  for  the  practitioner. — Chicago 
Miui.  Joum.  and  Examiner.  Jan.  1876. 

Prof.  Dalton  has  discussed  conflicting  theories  and 
conclusions  regarding  physiological  questions  with  a 


its  sixth  edition  with  the  addition  of  uhout  fifty  per  cert, 
of  new  matter,  chiefly  in  the  departments  of  patho- 
logical chemistry  and  the  nervous  system,  where  the 
principal  advances  have  been  realized.  AVith  so  tho- 
rough revision  and  additions,  that  keep  the  work  well 
up  to  the  times,  its  continued  p'^pularity  may  be  confi- 
dently predicted,  notwitli>tanding  the  competition  it 
m.ay  encounter.     The  publisher's  work  is  admirably 


fairness,  a  fuln^ess.  and  a  conciseness  which  lend  fresh- 1  'ione.-Sr.  Louis  Med.  and  Surg.  Joum.,  Dec.  1875. 
ness  and  vigor  to  the  entire  book.  But  his  discussions  We  heartily  welcome  this,  the  sixth  edition  of  this 
have  been  so  guarded  by  a  refusal  of  admission  to  those  admirable  text  book,  than  which  there  are  none  of  equal 
speculative  and  theoretical  explanations,  which  at  best  I  brevity  more  valuable.  It  is  cordially  recommended  by 
exist  in  the  minds  of  observers  themselves  as  only  pro-  <  the  Professor  of  Physiology  in  the  University  of  Louisi- 
babilities,  that  none  of  his  readers  need  be  led  into  i  ana,  as  by  all  competent  teachers  in  theUnited  States, 
grave  errors  while  making  them  a  study. — The  Medical  \  and  wherever  the  English  language  is  read,  this  book 
Record,  Feb.  19, 1876.  f  has  been  appreciated.  The  present  edition,  with  its  316 

The  revision  of  this  great  work  hasbroughtitforward  |  admirably  execul»id  illustrations,  has  been  carefully 
with  the  physiological  advances  of  theday,  and  renders  !  ••«''^«<1  ^"^  very  much  enlarged,  although  its  bulkdoes 
it,  as  it  has  ever  been,  the  finest  work  for  students  ex-  i  not  seem  perceptibly  incre.ased.-iVen.  Orleans  Medical 
Unt.-KaskvilleJourn.o/Med.  and  Surg.,  Jan.  1876.      \  «»'^  SargtcalJournaL  March,  18<  6. 

For  clearness  and  perspicuity,  Dalton's  Physiology  I  The  present  edition  is  very  much  superior  to  every 
commended  itself  to  the  student  vears  ago.  and  wa.s  a  o*^"'  l°\  °"ly  \f  ,"i^* '^^"°^/  ^  subject  up  to  the 
pleasant  relief  from  the  verbose  productions  which  it  ,  "nes,  but  that  .t^doss  so  niore  fully  and  sati.sfactorily 
supplanted.  Physiology  has.  however,  made  many  ad- i  ?^«n^"yP';7'°".^':'J'''"°Takeitaltogetherit  remains 
vances  since  then-and  while  the  style  has  been  pre-  |  .nourhumbleopin.on,thebest  text  book  on  physiology 
served  intact,  the  work  in  the  present  edition  has  been  , '°  any  '''"d  "'^ language— r/ie  Chmc,  Nov.  6. 18,5. 
broughtupfullyabreastofthetimes.  Thenewchemical  As  a  whole,  we  cordially  recommend  the  work  as  a 
notation  and  nomenclature  have  also  been  introduced  '  text-book  for  the  student,  and  as  one  of  the  best. — 
into  the  present  edition.  Notwithstanding  the  multi-  ,  The  Journal  of  Xervous  and  Mental  Disease,  Jan.  1S76. 
plicity  of  text-books  on  physiology. this  will  lose  none!  still  holds  its  position  as  a  masterpiece  of  lucid  writ- 
or  its  old  time  popularity.  The  mechanical  execution  ;„„_  ^^^1  is,  we  believe,  on  the  whole,  the  best  book  to 
of  the  work  is  all  that  could  be  desired.— PtniWswZar  1  pj^ce  in  the  hands  of  the  student.— London  Students' 
Journal  of  Medicine,  Dec.  1875 .  1  Journal 


HLASSEN  [ALEXANDER], 

^^  Profe.ii'or  in  the  Royal  Polytechnic  School,  Aix  la-Chapelle. 

ELEMENTARY    QUANTITATIVE    ANALYSIS.     Transl.itecl  with 

notes   and  additions  by  Edgar  F.   Smith,   Ph.D.,  Assistant  Prof,  of  Chemistry  in  the 

Towne  Scientific  School,  Univ.  of  Penna.     In  one  handsome  royal  12mo.  volume,  of  324 

pages,  with  illustrations;  cloth,  $2  00.     {Just  RpmcIij.) 

It  is  probably  the  best  manual  of  an  elementary  i  advancing  to  the  analysis  of  minerals  and  snch  pro. 

natnre  extant,  insomuch  as  its  methods  are  the  best,     ducts  as  are  met  with  in  applied  chemistry      It  is 

It  teaclies  by  examples,   commencing   with   single  i  an  iodi.spensable  book  for  students  in  chemistry. — 

determinations,  followed  by  separations,  and  then     Boston  Joum.  of  Chemistry,  Oct.  1878. 

(^ALLOWAY  (EGBERT),  F.C.S., 

^^  Prof  of  Applied  Chemistry  in  the  Royal  College  of  Science  for  Ireland,  etc. 

A  MANUAL  OF  QUALITATIVE  ANALYSIS.  Prom  the  Fifth  Lon- 
don Edition.  In  one  neat  royal  12mo.  volume,  with  illustrations ;  cloth,  $2  75.  {Lately 
Iss  ued.) 

'DO  WMAN  [JOHN  E.) ,  MJ). 
INTRODUCTION  TO  PRACTICAL  CHEMISTRY,  INCLUDING 

ANALYSIS.  Sixth  American, from  the  sixth  and  revised  London  edition.  With  numer- 
ous  illustrations.     In  one  neat  vol.,  royal  12mo.,  cloth,  $2  25. 

QREENE  [WILLIAM  h7)7m.K, 

^-^    -        Deraonstrotor  <if  Chemistry  in  Med.  Dept  ,  Univ.  of  Penna. 

A  MANUAL  OF  MEDICAL  CHEMISTRY.    For  the  Use  of  Stu'lents. 

Bnsed  upon  Bowman's  Medical   Chemistry.     In  one  royal    12mo.  volume  of  about  400 
pnges.     With  illustrations.     {Shortly.) 

T?EMSEN[IRA),  M.D.,  Ph.D., 

Prof  "jisor  of  Chemistry  in  the  Johns  Hopkins  University,  Fnllimore. 

PRINCIPLESOF  THEORETICAL  CHKMISTIIY,  with  special  reference 

to  the  Constitution  of  Cheinicnl  Compounds.   In  one  handsome  royal  12mo.  vol.  of  over 
232  pages:  cloth,  $1  50.     {Just  Issued.) 

'OHLER  AND  FITTIG. 
OUTLINES  OF  ORGANIC  CHEMISTRY.     TransLated  with  Ad- 

ditions  from  the  Eighth  German  Ed.     By  Ira.  Rkmskn,  M.D.,  Ph.D.,  Prof,  of  Chein. 
and  Physics  in  Williams  College,  Mass.  In  one  volume,  royal  12  mo.of550  pp.,  cloth,  $3. 


w 


10 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Chemistry). 


pOWNES  {GEORGE),  Ph.D. 

A  MANUAL  OF  ELEMENTARY  CHEMISTRY;  Theoreticnl  and 

Practical.    Revised  and  corrected  by  Henry  Watts,  B.A.,  F  R.S.,  author  of  "A  Diction- 
ary of  Chemistry,"  etc.    With  a  colored  plate,  and  one  hundred  and  seventy-seven  illus- 
trations.   A  new  American,  from  thi  twelfth  ;ind  enlarged  London  edition.     Edited  by 
Robert  Bridges,   M.D.        In    one  larje   royal  12mo.   volume,  of  over  1000  pages; 
cloth,  $2  75  ;  leather,  $3  25.     (Jiist  Ready  ) 
Two  careful  revisions  by  Mr.  Wntts,  since  the  appearance  of  the  last  American  edition  of 
"  Fownes,"  have  so  enlarged  the  work  that  in  England  it  has  been  divided  into  two  volumes.    In 
reprinting  it,  by  the  use  of  a  sniaU  and  exceedingly  clear  type,  cast  for  the  purpose,  it  has  been 
found  possible  to  comprise  the  whole,  without  omission,  in  one  volume,  not  unhandy  for  study  and 
reference.   The  enlargement  of  the  work  has  induced  the  American  Editor  to  confine  his  additions 
to  the  narrowest  compass,  and  he  has  accordingly  inserted  only  such  discoveries  as  have  been  an- 
nounced since  the  very  recent  appearance  of  the  work  in  England,  and  has  added  the  standards 
in  popular  use  to  the  Decimal  and  Centigrade  systems  employed  in  the  original. 

Among  the  additions  to  this  edition  will  be  found  a  very  handsome  colored  plate,  representing 
a  number  of  spectra  in  the  spectroscope.  Every  careh.as  been  taken  in  the  typographical  execu- 
tion to  render  the  volume  worthy  in  every  respect  of  its  high  reputation  and  extended  use,  and 
though  it  has  been  enlarged  by  more  than  one  hundred  and  fifty  pages,  its  very  moderate  price 
will  still  maintain  it  as  one  of  the  cheapest  volumes  accessible  to  the  chemical  student. 

what  formidable  magnitude  with  its  more  than  a 
thim-aud  page.s,  but  with  less  than  this  no  fair  rejire- 
senlatiou  of  chemistry  as  it  now  is  can  be  given.  The 
type  is  small  but  very  clear,  and  the  sections  are  very 
lucidly  arranged  to  facilitate  study  and  reference. — 
Mf.i  a7id  Surg.  Rfprrter,  Ang  .i,  1S7S. 
The  work  is  too  well  known  to  American  students 


This  work,  inorganic  and  organic,  is  complete  in 
one  convenient  volume.  In  its  earliest  editions  it 
was  fully  up  to  the  latest  advancements  and  theo- 
ries of  that  lime.  In  its  present  form,  it  presents, 
in  a  remarkably  convenieul  and  satisfactory  raau- 
U'T,  the  principles  and  leading  facts  of  the  chemist  rj 
of  to-day.  Conceruiug  the  manner  in  which  tlie 
various  subjects  are  treated,  much  de-erves  to  be 
said,  and  mostly,  too,  in  piais-e  of  thp  book.  A  re- 
view of  such  a  work  at  Fowne^'s  Cheiiii^lry  within 
the  limits  of  a  book-notice  for  a  medical  Meekly  is 
simply  outoftlie  question. — Cincinnati  Lanutt  and 
Clinic,  Dhc.  U,  1S7S. 

When  we  state  that,  in  our  opinion,  the  present 
edition  sustains  in  every  respect  tie  high  reputation 
which  its  predecessor's  have  atquiied  and  enjoyed, 
we  express  therewiih  our  full  belief  in  iis  intrinsic 
value  as  a  text-book  and  work  of  reference. — Am. 
Journ.  of  Phnrm.,  Aug.  1S7S. 

The  conscientious  care  which  has  been  bestowed 
upon  it  by  the  American  and  English  editors  renders 
it  still,  perhaps,  the  best  book  fir  the  student  and  the 
practitioner  who  would  keep  alive  the  acqtii.sitions 
of  his  student  days.    It  has,  indeed,  reached  a  some- 


to  need  any  extended  notice;  sttflice  it  to  say  that 
the  revision  by  the  English  editor  has  been  faithfully 
done,  and  that  Professor  Bridges  has  added  some 
fresh  and  valuable  matter,  especially  in  the  inor- 
ganic chemistry.  Tlie  book  has  always  been  a  fa- 
vorite in  this  country,  and  in  its  new  shape  bids 
fair  to  retain  all  its  former  prestige.. — Botston  Jour, 
of  Chemistry,  Aug.  1S78. 

It  will  be  entirely  unnecessary  for  us  to  make  any 
remarks  relating  to  the  general  characterof  Fownes' 
Manual.  For  over  twenty  years  it  has  held  the  foie- 
most  place  as  a  text-book,  and  the  elaborate  and 
thorongh  revisions  which  have  been  made  from  time 
to  time  leave  lit  tie  chance  for  any  wide  a  wake  rival  to 
step  before  it. — Vanadinn  Pliarm.  Jour.,  Aug.  1878. 

As  a  manual  of  chemistry  it  is  without  a  superior 
in  the  language. — Md.  Med.  Jour.,  Aug.  1&78. 


ATTFIELD  [JOHN],  Ph.D., 
Professor  of  Practical  Chemistry  to  the  Pharmaceutical  .Society  of  Great  Britain,  &c. 

CHEMISTRY,  GENERAL,  MEDICAL,  AND  PHARMACEUTICAL; 

including  the  Chemistry  of  the  U.  S.  Pharmacol  ceia.   A  Manual  of  the  General  Principles 

of  the  Science,  and  their  Application  to  Medicine  and  Pharmacy.    Eighth  edition  revised 

by  the  author.  In  one  handsome  royal  12mo.  volume  of  700  pages,  with  illustrations. 

Cloth,  $2  60  ;   leather,  $.3  00.      (Just  Ready.) 

We   have    repeatedly   expressed    our   favorable  j  of    chemistry  in   all   the   medical   collfges  in   the 

opinion  of  this  work,  and  on  the  appearance  of  a  I  United  States.     The  present  edition  contains  such 

new  edition  of  it,  little  remains  for  us  to  say,  ex-  '  alterations  and  additions  as  seemed  necessary  for 

cep-  that  we  expect  this  eighth   edition   to  be  as    the  demonstrati )n  of  the  latest   developments  of 

iudispensuble  to  us  as  the  seventh   and  previous  ,  chemical  principles,  and  the  latest  applications  of 

editions  have  been.     While  the  general  plan  and  I  chemis'ry  to  piiarmacy.     Il  is  scarcely  necef-sary 

airangement   have   been    adhered   to,   new   matter  '  for  us  to  say  that  it  exhibits  chemistry  iu  its  pre- 

has  been  added    covering  the  observationf-  made  i  sent  advanced  state. — Cincinnati  Medical  litws, 

since  the  former  edition      The  present  ditfers  from  j  April,  1879. 

the  preceding  one  chiefly  in  these  alterations  and  j  T|,p  popularity  which  this  work  has  enjoyed  is 
in  about  ten  piges  of  useful  tabb-s  added  lo  the  i  owing  to  the  origioal  and  clear  disposition  of  the 
appendix  -Am  Jonr.  of  Ph-irmruy,  .May,  ls/9.  f^g,^  of  the  science,  the  accuracy  of  the  details,  and 

A  standard  work  like  Attfield's  Chemistry  need  |  the  omission  of  much  which  freights  many  treatises 
only  be  mentioned  by  its  name,  without  further  i  h>-avily  without  brlngingcorrespondinginstruction 
comments  The  present  edition  contains  such  al  t  to  the  reader.  Dr.  Attfield  wiites  for  students,  and 
teralious  and  additions  as  seemed  neceisary  for  '  primarily  f.)r  medical  students;  be  always  has  an 
the  demonstration  of  the  latest  developments  of  I  eye  to  the  pharmacopoeia  and  its  offici  nal  prepara- 
chfmical  prini'ipUs,  and  the  lale-t  applications  of  !  tions ;  and  he  is  continually  puttiug  the  matter  in 
chemistry  to  pharmacy.  The  author  has  bestowed  I  the  texi  so  that  it  responds  to  the  questions  with 
arduons  l;ibor  on  the  revision,  and  the  ex'ent  of  which  each  section  is  provided.  Thus  the  student 
the  information  thus  introduced  may  be  estimated  I  learns  easily,  and  can  always  refresh  and  test  his 


from  the  fact  that  the  index  '-ontains  three  hun- 
dred new  references  relating  to  additional  maler 
ial. — Druggists'  Circular  and  Chemical  Gizttte. 
May,  1S79. 


knowledge. — Med  andSurg.  Reporter,  Apriil9,'79. 
We  noticed  only  about  two  vears  and  a  half  ago 
tbe   Dulilication  of  the  preceding  edition,  and   re- 
marked upon  the  exceptionally  valuable  character 


This  very  popular  and  meritorious  work  has  '  of  the  work.  The  work  now  i  aclndes  the  whole  of 
now  reached  its  eighth  edition,  which  fact  speaks  I  the  chemistry  of  the  phaimacopreia  of  the  nniled 
In  the  highest  terras  in  commendation  of  its  excel-  j  States,  Great  Britain,  and  India. — New  Remedies , 
lence.     It  has  now  become  the  principal  text-book  1  May,  1S79. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Chemistry). 


11 


T?LOXAM  (.C.L.), 

-*-^  Professor  of  Chemistry  in  King's  College,  London. 

CHEMISTRY,  INORGANIC  AND  ORGANIC.    From  the  Second  Lon- 

don  Edition.     In  one  very  handsome  octavo  volume,  of  700  pages,  with  about  300  illus- 
trations.    Cloth,  $4  GO  I  leather,  $5  00.     (Lately  Issued.) 


We  have  in  this  work  a  complete  and  most  excel- 
lent text-book  for  the  use  of  schools,  and  can  heart- 
ily recommeud  it  as  such. — Boston  Med.  and  Surg. 
Journ.,  May  2S,  1S74. 

The  above  is  the  titleof  a  work  which  we  can  most 
conscieatlously  recommend  to  students  of  chemis- 
try. It  Is  as  easy  as  a  work  on  chemistry  could  be 
made,  at  the  same  time  that  it  presents  a  full  account 
of thatscieuce  as  it  now  stands.  We  have  spoken 
of  the  work  as  admirably  adapted  to  the  want>  of 
students;  it  is  quite  as  well  suited  to  the  require- 
ments of  practitioners  who  wish  to  review  their 
chemistry,  or  have  occasion  to  refresh  their  memo- 
ries on  any  point  relating  to  it.  In  a  word,  it  is  a 
book  to  be  read  by  all  who  wish  to  know  what  is 
the  chemistry  of  the  present  day. — American  Prac 
titioner,  i\ov.  1873. 


It  would  be  difficult  for  a  practical  chemist  and 
teacher  to  find  any  material  fault  with  this  most  ad- 
mirable treatise.  The  author  has  given  us  almost  a 
c)  clop£edia  within  the  limits  of  aconvenient  volume, 
and  has  done  so  without  penning  the  useless  para- 
graphs too  commonly  making  up  a  great  part  of  the 
bulk  of  many  cumbrous  works.  The  progressive 
scientist  is  not  disappointed  when  he  looks  for  the 
record  of  new  and  valuable  processes  and  discover- 
ies, while  the  cauti^'us  conservati'^e  does  not  find  its 
pages  monopolized  by  uncertain  theories  and  specu- 
lations. A  peculiar  point  of  excellence  is  the  crys- 
tallized form  of  expression  in  which  great  truths  are 
expressed  in  very  short  paragraphs.  One  is  surprised 
at  the  brief  space  allotted  to  an  important  topic,  and 
yet,  after  reading  it,  he  feels  that  little,  if  any  more 
should  have  been  said.  Altogether,  it  is  seldom  you 
.see  a  text-book  so  nearly  faultless.  —  Cincinnati 
Lancet   Nov.  1S73. 


flLOWES  (FRANK),  D.Sc.  Lovdon. 

^^  Senior  Science- Ma.iter  at  the  HighSchnof)  Newcastle-underLyme,  etc. 

AN  ELEMENTARY  TREATISE  ON  PRACTICAL  CHEMISTRY 

AND    QUALITATIVE    INORGANIC    ANALYSIS.     Specially  adapted  for  Use  in  the 

Laboratories  of  Schools  and  Colleges  and  by  Beginners.  From  the  Second  and  Revised 

English  Edition,  with  about  fifty  illustrations  on  wood.      In  one  very  handsome  royal 

12mo.  volume  of  372  pages  :  cloth.  §2  50.      (Now  Ready.) 

It  is  short,  concise,  and  eminently  practical.    We  ;  are  so  simple,  and  yet  concise,  as  to  be  interesting 

therefore  heartily  commend  it  to  sluden  s,  ami  e-pe-  ;  and   intelligible.     The  work  is   unincumbered  with 

cially  to  (hose  who  are  obliged   to  dispens*^  with  a  [theoretical    deductions,  dealing    wholly    with    the 

master.     Of  course,  a  teacher  is  in  every  wh y  desi-  '  practical  matter,  which  it  is  the  aim  of  this  compre- 

rable,  but  a  good  degree  of  technicil  skillaud  prac-    hensive  textbook  to  impart.     The  accuracy  of  the 

tical    knowledge   can    be    attained  with    no    other    analytical  methods   are  vouched   fur   from  the  fact 

instructor  than   the  very  valuable   handbook  now  j  that   they  have  all   been  worked   through    by   the 

under  consideration. — St  Louis  Clin.  Record,  Oct.  1  author    and    the   members  of  his  ciass.  from   the 

ls77.  I  printed  text.   We  can  heartily  recommend  the  work 

The  work  is  so  written  and  arranged  that  it  can  be  1  '«  t*^*  student  of  chemistry  as  being  a  reliable  and 

comprehended  by  the  student  without  a  teacher,  and  \  <-omrrf_hen.sive  one. -Druggists'  Advertiser,  Oct. 

the  descriptions  and  directious  forthe  various  work  '  '^"'  'S77. 


KN4PP'S  TECHNOLOGY;  orChemlstry  Applied  to 
the  Arts,  and  to  Manufactures.  With  American 
additions  by  Prof.  Walter  R.  Joh.vson.     In  two  | 


very  handsome  octavo  volumes,  with  .OOO  wood 

engravings,  cloth,  $6  00. 


pARRISH  [EDWARD], 

Late  Prof essor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy. 

A  TREATISE  ON  PHARMACY.     Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.    With  many  Formulae  and 

Prescriptions.     Fourth  Edition,  thoroughly  revised,  by  Thomas  S.  Wikgand.      In  one 

handsome  octavo  volume  of  977  pages,  with  280  illustrations;  cloth,  S'S  50;  leather,  $6  50. 

ilMtely  Issued.) 

Of  Pr   Parrish's  great  work  on  pharmacy  it  only  \  the  work,  not  only  to  pharmacists,  but  also  to  the 

remains  to  be  said  that  the  editor  has  accomplished  ,  multitude  of  medical  practitioners  win  are  obliged 

his  work  so  well  as  to  maintain,  in  this  fourth  edi-  i  to  compound  their  own  medicines.    It  will  ever  hold 

tion,  the  high  standard  of  excellence  which  it  had    an  honored  place  on  our  own  bookshelves. — Dultlin 

a  t  tai  ned  i  n  jirevio  us  editions,  under  I  he  editorship  of  I  Med.  Press  and  Circular,  Aug.  12,  1S74. 

Its  accomplished  author.     This  has  not  been  accom 

pi ished  without  much  labor, and  manyadditionsand 


We  expressed  our  opinion  of  a  former  edition  in 


improvements,  involving  Changes  in  the  arrange- '«""•;  "f  ""^l'"^'/"  P™'.^'"' f '"^  "I".""'?  ",?  '""  „ 
mentof  the  several  parts  of  the  work,  and  (he  ad.li- 1  '»  <l;';;»f.'  I''"'"  "'"'  •"'-''-»  >»   "f-'-^-ee  t"  the  pre- 

tion  of  much  new  matter.     With  the  modiflcations  I  ««"' «d'"<"J-  'K-*  •'in'^^J^'^  °\^''''^^,''.  V^f''''*'V'  '** 
thuseirecteditcoustitutes,as  nowpresented, acorn.  !«:'''M'e>ent  hands.  It. saJ,ook  with  whul.no  pharm 

pendium  of  the  science  and  art  indispensable  ,„  the  I  ='-:^[  ,«=«" '''."P'^""'''  f"''  f'"""  «;1'>^'''  ""  I'liyMcan  can 
'^  '  fail  to  derive  Miiicl.  .nformation  of  value  to  bin.   in 


pharmacist,  and  of  the  utmost  value  to  every 
practiiioner  of  medicine  desirous  of  familiarizing 
himself  with  the  pharmaceutical  preparation  of  the  \ 
articles  which  he  prescribes  forhis  patients.  —  Clii-' 
eago  Med.  ■/'ottrn.,  July,  1S74. 
The  work  is  eminently  pra'tlcal,  and  has  the  rare 


practice. — Pacific  Med  aiidSurgJimrn.,  Jane, "I  i. 

Perhaps  one,  if  not  the  most  important  book  upon 
pharmacy  which  has  appeared  in  the  English  lan- 
guage has  emanated  from  the  transatlantic  press. 
"  Parrish's  Pharmacy  "is  a  well-known  work  on  this 
merit  of  being  readable  a  tid  interesting,  while  it  pre-  side  of  the  water,  and  the  fact  shows  us  that  a  really 
serves  a  strict  ly-cien  I  ificcharacter  The  whole  woik  '  useful  work  never  becomes  merely  local  In  Us  fame, 
reflects  the  greatest  credit  on  author. editor  and  pub  Thanks  to  the.iuillcious  editing  of  Mr.  Wiegand,  the 
lisber  It  will  con  vfy  so  me  idea  of  the  libera  llty  whirh  posthumous  edition  of  "Parrish"  has  been  saved  to 
has  been  bestowed  upon  its  production  when  we  men- '  the  public  with  all  the  mature  experience  of  its  au- 
tion  that  I  here  are  no  less  than  2S(i  carefully  executed  thor.  and  perhaps  none  the  worse  for  a  dash  of  new 
Illustrations.  In  conclusion,  we  heanily  reconmieud    blood. — Land.  Pharm.  Journal,  Oct.  17,  1874. 


12  Henry  C.  Lea's  Son  &,  Co.'s  Publications — {Mat.  Bled,  and  Therap.). 
pARQUHARSON  [ROBERT),  M.D., 

Lecturer  on  31'iterin  Mf.dioa  nt  St.  Mary's  Ilospitnl  Medical  School. 

A  GUIDE  TO  THERAPEUTICS  AND  MATERIA  MEDICA.     Se- 

cond  Amerif^an  edition,  revised  by  the  Author.  Enlarged  aod  adapted  to  the  U.  S. 
Pharmacopoeia.  By  Fkank  Woodburv,  M.D.  In  one  neat  rojal  12ino.  volume  of  498 
pages:  cloth,  $2.25.      {Just  Ready.) 


The  appearance  of  a  new  edition  of  this  conve- 
nient aod  handy  book  in  less  than  two  years  may 
certainly  be  taken  as  an  indication  of  its  useful- 
ness. Its  convenient  arrangement,  and  its  terse- 
ness, and,  at  the  same  time,  completeness  of  the 
information  given,  make  it  a  handy  book  of  refer- 
ence.— Am.  Juurn.  of  Pharmacy,  Jane,  1879. 

The  early  appearance  of  a  second  elition  of  Dr. 
Farqnharson's  work  bears  sufficient  testimony  to 
the  appreciation  of  it  by  American  readers.  The 
plan  is  such  as  to  bring  the  character  and  action  of 
drugs  to  the  eye  and  mind  with  clearness  Tbe 
care  with  which  both  author  and  ed  tor  have  done 
their  work  is  conspicuous  on  every  page. — Med.  and 
Surg.  Reporter,  May  31,  1S70. 

This  work  contains  in  moderate  compass  such 
well-digested  facts  concerning  the  physiological 
and  therapeutical  action  of  remedies  as  are  reason- 
ably established  up  to  the  pre>ent  time.  By  a  con- 
venient arrangement  the  coriesponding  eliects  of 


each  article  in  healih  and  disease  are  presented  in 
parallel  cflumns,  not  only  rendering  reference 
easier,  but  also  impressing  the  facts  more  strougly 
upon  the  mind  of  the  reader.  The  book  has  beeu 
adapted  to  the  wants  of  the  American  student,  and 
copious  ni)tes  have  been  introduced,  embodying  the 
latest  revision  of  f^e  Pharmacopojia,  together  wi'h 
the  antidotes  to  the  more  promiueut  poisons,  and 
such  of  the  newer  remedial  aeent.->as  seemed  neces- 
sary to  the  completeness  of  the  work.  Tables  of 
weights  and  mea.sures,  and  a  good  alphabetical  in- 
dex end  the  volume. — Drngyi.sib'  Circular  and 
Chemical  Gazette,  June,  1S79. 

It  is  a  pleasure  to  think  that  the  rapidity  with 
which  a  second  edition  is  demanded  may  be  taken 
as  an  indication  that  the  sense  of  appreciation  of  the 
value  of  reliable  information  regarding  the  use  of 
remedies  i^  not  entirely  overwhelmed  in  the  cultiva- 
tion of  pathological  studies,  characteristic  of  the  pre- 
sent day.  This  work  certainly  merits  the  success  it 
has  so  quickly  achieved. — New  Remediex,  July,  '79. 


OTILLE  (ALFRED),  M.D., 

Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA  ;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History. 
Fourth  edition,  revised  and  enlarged.  In  two  large  and  handsome  8vo.  vols,  of  about  2000 
pages.     Cloth,  $10;  leather,  $12.     (Lately  Issued.) 


It  is  unnecessary  to  do  much  more  than  to  an- 
nounce the  appearance  of  the  fourth  edition  of  this 
well  known  and  excellent  work. — Brit,  and  For. 
Med.-Chir.  Review,  Oct.  Ib7.i. 

Forall  who  desire  a  complete  work  on  therapeutics 
and  materia  medicafor  reference,  incasesiuvolving 
medico-legal  questions,  as  well  as  for  information 
coucerniug  remedial  agents,  Dr.  Still6's  is  "par  ex- 
cellence" the  work.  The  work  being  out  of  print,  by 
the  exhaustion  of  former  editions,  the  author  has  laid 
the  profession  under  renewed  obligations,  by  the 
careful  revision,  importantadditions,  and  timely  re 
issuing  a  work  not  exactly  supplemented  by  any 
other  in  the  English  language,  if  in  any  language. 
The  mechanical  execution  handsomely  sustains  the 
well-known  skill  and  good  taste  of  the  publisher. — 
St.  Louis  Med.  and  Surg.  Journal,  Dec.  1874. 

From  the  publication  of  the  first  edition  "Still^'s 
Therapeutics"  has  been  one  of  the  classics;  its  ab- 
sence from  our  libraries  would  create  a  vacuum 
which  could  be  filled  by  no  other  work  in  the  lan- 
gaage,  audits  presence  supplies,  in  the  two  volumes 


of  the  present  edition,  a  whole  cyclopjedia  of  thera- 
peutics.—  Chicago  Medical  Journal,  Y&h.  lS"o. 

The  rapid  exhaustion  of  three  editions  and  the  uni- 
versal favor  with  which  the  work  has  been  received 
by  the  medical  profession,  are  sufficient  proof  of  its 
excellence  as  a  repertory  of  practical  and  useful  in- 
formation for  the  physician.  The  edition  before  us 
fully  sustains  this  verdict,  as  the  work  has  been  care- 
fully revised  and  in  some  portions  rewritten,  bring- 
ing it  up  to  the  present  time  by  the  admission  of 
chloral  and  crotonchloral,  nitrite  of  amyl,  bichlo- 
ride of  methylene,  methylic  ether,  lithium  com- 
pounds, gelseminum,  and  other  remedies. — Am. 
Journ.  of  Pharmacy,  Feb.  187.5. 

We  can  hardly  admit  that  it  has  a  rival  in  the 
multitude  of  its  citations  and  the  fulness  of  its  re- 
search into  clinical  histories,  and  we  must  assign  it 
a  place  in  the  physician's  library;  not,  indeed,  as 
fully  representing  the  present  state  of  knowledge  in 
pharmacodynamics,  but  asbyfarthe  most  complet* 
treatise  upon  the  clinical  and  practical  side  of  the 
question. — Boston  Med.  and.  Surg.  Journal,  Nov.  5, 
1874. 


QRIFFITH  {ROBERT  E.),  M.D. 

A  UNIVERSAL  FORMULARY,  Containing  the  Methods  of  Prepar- 
ing and  Administering  Officinal  and  other  Medicines.  The  whole  adapted  to  Physiciars  and 
Pharmaceutists.  Third  edition,  thoroughly  revised,  with  numerous  additions,  bj  John  M. 
Maisch,  Professor  ofMateriaMedica  in  the  Philadelphia  College  of  Pharmacy.  In  one  large 
and  handsome  octavo  volume  of  about  800  pp.,  cl.,  $4  50  ;  leather,  $5  50.  {Lately  Issued.) 


To  (he  druggist  a  good  formulary  is  simply  indis- 
pensable, aud  perhaps  no  formulary  has  beeu  more 
extensively  used  than  the  well-known  work  before 
us.  Many  physicians  have  toofficiate,  also,  as  drug- 
gists. This  is  true  especially  of  the  country  physi- 
cian, and  a  work  which  shall  teach  him  the  means 
by  which  to  administer  or  combine  his  remedies  in 
the  most  efficacious  and  pleasant  manner,  will  al- 
ways hold  its  place  upon  his  shelf.  A  formulary  of 
this  kind  is  of  benefit  also  to  the  city  physician  in 
largest  pra,ciice. —Cincinnati  Olinic,  Feb.  21, 1S74. 


A  more  complete  formulary  than  ills  in  its  pres- 
ent form  the  pharmacist  or  physician  could  hardly 
desire.  To  the  first  some  such  work  is  indispensa- 
ble, and  it  is  hardly  les.-!  essential  to  the  jiractitioner 
who  compounds  his  own  medicines.  Much  of  what 
is  contained  in  the  introduction  ought  to  be  com- 
mitted to  memory  by  every  student  of  medicine. 
As  a  help  to  physicians  it  will  be  found  invaluable, 
and  doubtless  will  make  its  way  into  libraries  not 
already  supplied  with  a  standard  work  of  the  kind  . 
— The  American  Practitioner,  Louisville,  July,  '74. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (3Iat.  Med.  and  Therap.),  13 


CfTILLE  [ALFRED),  31. D.,  LL.D.,  and  llfAISCH  [JOHN  M.).  Ph. 

AJ        Prof,  of  Theory  and  Practice,  of  Medicine  J-U.        Pn^f.  of  Mat.  Med.  and  Bot. 


in  Ph  i!n . 
and  of  Clinical  Med.  in  Univ.  of  Pa.  '  Coll.  Phorrnoci/,  Seci/.tothe.  American 

Phnrmacetiticu)  Ansocio.tion. 

THE   NATIONAL  DISPEXSATOPvY  :  Containincj  the  Natural  History, 

Chemistry,  Pharmacy,  Actions  and  Uses  of  Medicines,  including  those  recncrnized  in 
the  Pharmacopoeias  of  the  United  States,  Great  Britain,  and  Germany,  wilh  numer- 
ous references  to  the  French  Codex.  Second  edition,  thnrouf;hIy  revised,  with  numerous 
additions.  In  one  very  handsome  octavo  volume  of  1692  paees,with  239  illustrations. 
Extra  cloth,  $6  75;  leather,  raised  bands,  §7  50.  {Noio  Ready  ) 
Preface  to  the  Second  Edition. 

The  demand  which  has  exhausted  in  a  few  months  an  unusually  large  edition  of  ihe  Xationnl 
Dispensatory  is  doubly  gratifying  to  the  authors,  as  showing  that  tbey  were  correct  in  thinkinst 
that  the  want  of  such  a  work  was  felt  by  the  medical  and  pharmaceutical  professions,  and  that 
their  efforts  to  supply  that  want  have  been  acceptable.  This  appreciation  of  their  labors  has 
stimulated  them  in  the  revision  to  render  the  volume  more  worthy  of  the  very  marked  favor 
with  which  it  has  been  received.  The  first  edition  of  a  work  of  such  magnitude  mu«t  necessarily 
be  more  or  less  imperfect ;  and  thous;h  but  litt'e  that  is  new  and  important  has  been  brought 
to  light  in  the  short  interval  since  its  publication,  yet  the  length  of  time  during  which  it  was 
passing  through  the  press  rendered  the  earlier  portions  more  in  arrears  than  the  la  er.  The 
opportunity  for  a  revision  has  enabled  the  authors  to  scrutinize  the  work  as  a  whole,  and  to 
introduce  alterations  and  additions  whereve-  there  has  seemed  to  be  occasion  for  imorove- 
ment  or  greater  completeness.  The  principal  changes  to  be  noted  are  the  introduction  of  seve- 
ral drugs  under  separate  headings,  and  of  a  large  number  of  drugs,  chemicals,  and  pharm;i- 
ceutical  preparations  classified  as  allied  drugs  and  preparations  under  the  heading  of  more 
important  or  better  known  articles  :  these  additions  comprise  in  part  nearly  the  entire  German 
Pharmacopoeia  and  numerous  articles  from  the  French  Codex.  All  new  investigations  which 
came  to  the  authors'  notice  up  to  the  time  of  publication   have  received  due  coBsideration. 

The  series  of  illustrations  has  undergone  a  corresponding  thorough  revision.  A  number  have 
been  added,  and  still  more  have  been  substituted  for  such  as  were  deemed  less  satisfactory. 

The  new  matter  embraced  in  the  text  is  equal  to  nearly  one  hundred  pages  of  the  first  edition. 
Considerable  as  are  these  changes  as  a  whole,  they  have  been  accommodated  by  an  enlargement 
of  the  page  without  increasing  unduly  the  size  of  the  volume. 

While  numerous  additions  have  been  mac'e  to  the  sections  which  relate  to  the  physiological 
action  of  medicines  and  their  use  in  the  treatment  of  disease,  great  care  has  been  taktn  to 
make  them  as  concise  as  was  possible  without  rendering  them  incomplete  or  obscure.  The 
doses  have  been  exjiressed  in  the  terms  both  of  troy  weight  and  of  the  metrical  system,  for  the 
purpose  of  mak'ng  those  who  employ  the  Dispensatory  familiar  With  the  latter,  and  paving  the 
way  for  its  introduction  into  general  use. 

The  Therapeutical  Index  has  been  extended  by  about  2250  new  references,  making  the  total 
number  in  the  present  edition  ab^ut  6000. 

The  articles  there  enumerated  as  remedies  for  particular  diseases  are  not  only  those  which, 
in  the  authors'  opinion,  are  curative,  or  even  beneficial,  but  those  also  which  have  at  any  time 
been  employed  on  the  ground  of  popular  belief  or  professional  authority.  It  is  often  of  as 
much  consequence  to  be  acquainted  with  the  worthlessness  of  certain  medicines  or  wilh  the 
narrow  limits  of  their  power,  as  to  know  the  weM  attested  virtues  of  others  and  the  conditions 
under  which  they  are  displayed.  An  additional  value  posse.-sed  by  such  an  Index  is.  that  it 
contains  the  elements  of  a  natur.al  classification  of  medicines,  founded  upon  an  analysis  of  the 
results  of  experience,  which  is  the  only  safe  guide  in  the  treatment  of  disease. 

This    evidence    of    siiccess,    seldom    paralleled,     intend  to  let  the  irrass  grow  under  (heir  feet,  but  (o 
shows  clearly  how  well  the  authors  have  wet  the    keep  the  work  up  to  the  time. — S^ew  Remedies,  Nov. 
existing  needs  of  the  pharmaceuticHl  and   medical  ,  1S79. 
professions.    Grutifyiug  as  it  mu^st  he  to  them,  they 

have  embraced  the  opportunity  offered  for  a  thor-  This  is  a  pr^at  work  by  two  of  the  ablest  writers  on 
ongh  revision  of  the  whole  work,  striving  ti)  em-  materia  mwhca  in  Amerna  The  authors  hsve  pro- 
brace  within  it  all  that  might  have  been  omitted  in  "luced  a  work  which,  tor  uccursoy  and  eompreheu.MT^- 
the  former  edition,  and  all  that  has  newly  appeared  "ess.  is  unsurpasswl  by  any  work  on  th"  siihject.  There 
of  sufficient  importance  during  the  time  of  its  col-  '^  no  book  in  the  hn-lisli  lanmiasi."  which  ooiitain.><  so 
lal.oration,  and  the  short  i  nterval  elapsed  since  Ihe  ■""''h  VHl.mble  information  on  the  various  articles  of 
previous  publication.  After  hiving  t^oae  carefully  "'^  materia  medira.  I  he^work  has  eost  the  authors 
through  the  volume  we  must  admit  that  theauthors  i  V"*"  of  laborions  study,  but  they  have  sucrecded  in 
have  labored  faithfully,  and  with  success,  in  main-  '  ."•oduein!^  a  di.open.ntory  which  is  not  only  nal,o„ol. 
talniog  the  high  character  of  their  work  as  a  com-  1  but  will  be  a  lasting  memorial  of  the  learnmg  and 
pendiuh.  meeting  the  requirements  of  the  day,  to  ;  "^-'V.'^  °J^  **'"  """"""-^  J^t""  P''0'1"'^^«^1  it.-h,Unburgli 
which  one  can  safely  turn  iu  quest  of  the  late.st  in-  !  M'diait  Journal,  Nov.  18/9. 

formation  ccincerning  everything  worthy  of  notice  in  ^  „g^  edition  of  this  great  work,  only  a  fevr 
connection  with  Pharmacy,  Materia  Medica,  and  months  after  the  first,  takes  us  bv  surprise.  Itin- 
Therapeutics.— .4»/i.  J-o!tr.  o/i'/iarwa^y,  Nov.  1 879.    jicates   the   high   appreciation  ot"  its  value  on  the 

It  is  with  great  pleasure  that  we  announce  to  our  part  of  physicians  and  pharmacists,  by  which  a 
readers  the  appearance  of  a  necnnd  edition  of  the  largo  edition  has  been  so  so.m  exhausted.  The  pre- 
National  Dispensatory.  The  total  exhaustion  of  the  sent  is  not  merely  a  repiiui  but  a  revision,  wiih 
first  edition  in  the  sliort  space  of  six  months,  is  a  important  additions  and  ipiodifications,  iv((nirlng  loo 
sufficient  testimony  to  the  value  placed  upon  the  pages  ot  new  mafer,  and  an  index  increased  by- 
work  by  the  profession.  It  appears  that  the  rapid  22.)0  references.  The  doses  are  stated  in  lioth  the 
sale  of  the  first  edition  must  have  induced  both  the  ordinary  and  metric  terms.  All  the  more  importsnt 
editors  and  the  publisher  to  make  preparations  for  material  ofthe  (ierman  and  French  I'liarmacopoeias 
a  new  edition  immediately  after  the  first  had  been  is  embodied.  It  is  liy  far  more  internal ional  or  uui- 
issued,  for  we  find  a  large  amount  of  new  matter  versal  than  any  other  book  of  the  kind  In  onr  Ian- 
added  and  a  good  deal  of  the  previous  text  altered  gnag^.  and  more  comprehensive  in  every  sen>e. — 
and  improved,  which  proves  that  theauthors  douot    Pacific  Med.  and  Snrg.  -/own.,  Oct.  1S79. 


14        Henry  C.  Lea's  Son  &  Co.'s  Publications — {Pathology,  &c.). 


flORNIL  (F.).  AND 

^         Prof,  in  the  Faculty  rtf  Med  ,  Ports. 


TDANVIER  (L.). 

.-*■*'         Prof  in  the  Cotlegeof  France. 

MANUAL  OF  PATHOLOGICAL  HISTOLOGY.     Translated,  with 

Notes  iind  Additions,  by  E.  0.  Shakespeare,  M.D.,  Pathologist  and  Ophthalmic  Surgeon 
to  Philiula   Hospital,  Lecturer  on  Refraction  and  Operative  Ophthalmic  Surgery  in  Univ. 
of  Penna.,  and  by  Henrv  C.  Simes    M  D.,  Deinonstrat.r  of  Pathological   Histology  in 
the   Univ.  of  Pa.     In  one  very  handsome  octavo  volume  of  over  700  pages,  with  over 
360  illustrations.      Cloth,  $5  50;   leather,  $(5  50.      {Just  Ready.) 
The  work  of  Cornil  and  Ranker  is  so  well  known  as  a  lucid  and  accurate  text-book  on  its 
important  subject,  that  no  apology  is  neeiled  in  presenting  a  translation  of  it  to  the  American 
profess  on.     It  is  on'y  necessary  to  say  that  the   labors  of  Drs.   Shakespeare  and  Simes  have 
been  by  no  means  confined  to  the  tafk  of  rendering  the  work  into  English.     As  it  appeared  in 
France,  in  successive  portions,  betwfen  IfiOS  and    187fi,  a  part  of  it,  at  least,  was  somewhat  in 
arrears  of  the  p  e.<ent  state  of  science,  while  the  diffuseness  if  other  portions  renf'ered  conden- 
sation  desirable      The  translators  have,  therefore,  sought  to  bring  the  work  up  to  the  day, 
and,  at  the  same  time,  to  reduce  it  in  size,  aj  far  as  practicable,  without  iurairing  its  cim- 
pleteness      These  changes  will   be  found  throughout  the  vo'ume,  the  most  extensive  being  in 
the  sections  devoted  to  Sarcoma,  Caicin'uia,  Tbbercilosis,  the  Bloodvessels,  the  Mammas,  and 
the  clas^ifiijation  of  turn  irs      Correspdnding  modifications  have  been  made  in  the  very  exten 
sive  and  beautiful  series  of  illustrations,  and  every  care  has  been  taken  in  the  typographical 
executi  n  to  render  it  one  of  the  most  attractive  volumes  which  have  issued  from  the  American 
press. 

U/'A  TSON  (  THOMAS),  M.D.,  §-c. 

LECTURES    ON    THE     PRINCIPLES    AND    PRACTICE    OF 

PHYSIC.  Delivered  at  King's  College,  London.  A  new  American,  from  the  Fifth  re- 
vised and  enlarged  English  edition.  Edited,  with  additions,  and  several  hundred  illustra- 
tions, by  Henry  Hartshorne,  M.D.,  Professor  of  Hygiene  in  the  Univer.^ity  of  Penn- 
sylvania. In  two  large  and  handsome  8vo.  vol.s.  Cloth,  $9  00  ;  leather,  $11  00.  {Lately 
Pubhshtd.)  

'EN WICK  {SAMUEL),  M.D., 

A.^aistnnt  Physician  to  the  London  Hospital, 

THE  STUDP]NT'S  GUIDE  TO  MEDICAL  DIAGNOSIS.     From  the 

Third  Revised  and  Enlarged  English  Edition  With  eighty-four  illustrations  on  wood. 
In  one  very  handsome  volume,  royal  12mo.,  cloth,  $2  25.      {Just  Issued.) 


F 


pREEN  ( T.  HENR  Y) ,  M.  D., 

^-^  Lecturer  on  Paiholagy  and  Morbid  Anatomy  at  Charing-Croxs  Ho,<ipita! Medical  School,  etc. 

PATHOLOGY  AND  MORBID  ANATOMY.    Third  American, from 

the  Fourth  and  Enlarged  and  Revised  English  Edition.     In  one  very  handsome  octavo 
volume  of  332  pages,  with  132  illustrations;   cloth,  $2  25.      {Just   Ready.) 
Thi.s  is  UQquesliooably  oae  of  the  best  nianiials  on 

the  bulijett  (if  pHtliology  and   iiirtrbiH  auHtomy  that 

can  be  pluced  in   the  student's  Iiands,  aud   we  are 


glad  to  see  it  kept  up  to  the  time.s  by  De>v  editions 
Each  edition  Is  carefully  revi  ed  by  the  author,  with 
the  view  of  loaking  it  include  tlie  most  recent  ad- 
vauce.s  in  pathology,  and  ot  omiiting  whatever  may 
have  become  ob.solete.— A'.  ¥.  Med.  Jour.,  Feb.  1879. 
The  treati.se  of  I>r.  Green  i«  compact,  clearly  ex- 
press d,  up  to  the  times,  and  popular  as  a  text-book, 
both  in  England  and  America.    The  cuts  are  suffi- 


ciently numerous,  and  u.snal  y  well  made.  In  the 
p  e-ent  edition,  such  new  matter  has  been  added  as 
was  necessary  to  embrace  the  later  results  in  patho- 
logical research.  No  doubt  it  will  continue  to  enjoy 
the  favor  it  has  received  at  the  hands  of  the  profes- 
sion.— Med   and  fi"rg.  Reporter,  Feb.  1,  1S79. 

For  practical,  ordinary  daily  ukc,  this  is  nndoubt- 
edly  the  best  treatise  that  is  offered  to  students  of 
patholoo;y  and  morbid  anatomy. — Cincinnati  Lan- 
cet and  Clinic,  Feb.  8,  1879.  » 


CHRISTISOi\"SDISr'ENSATORT.  With  copious  ad- 
ditions, and  "2:3  large  wood  engravings  By  R. 
Eglespiei.d  GR.FFnn,  M.D.  One  vol.  8vo.,  pp. 
1   00,  cloth.    $4  00. 

CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  OF 
Alcohomc  Liqfors  in  Hkalth  and  Disease.  New 
edition,  with  a  Preface  by  D.  F.  Condie.  M.D.,  and 
explanationsof  scientiflcwords.  In  oneneaH2inc. 
voiame,  pp.  178,  cloth.    60  cents. 

O  L.OGE'6  ATLAS  op  PATHOLOGICAL  HISTOLOGY 
Translated,  with  Notes  and  Additions,  by  Jo.^EPH 
Leidy,  M.  D.  In  one  volume,  very  large  imperial 
quarto,  with  820  copper-plate  figures,  plain  and 
colored,  cloth.     $-100. 

P.WY'S  TREAT. SE  ON  THE  FUNCTION  OF  DI- 
GESTION: its  Disorders  and  their  Treatment. 
From  the  second  I.,i>ndon  edition  In  one  hand- 
some volume,  small  ociavo,  cloth,  $2  W. 

LA  ROCHE  ON  YELLOW  FEVER. considered  in  its 
Historical,  Pathological.  Etiological,  and  Thera- 
pe'itical  Relations.  In  two  large  and  handsome 
octavo  volumes  of  nearly  1500  pp  ,  cloth.    $7  00. 


HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TiONs.     1  vol.  Svo.,  pp.  SOO,  cloth.    $.S  .^0. 

BARLOW'S  MANDAL  OF  THE  PRACTICE  OP 
WEDICINE.  With  Additions  by  D.  F.  Condib, 
II    0      1  vol.  8vo.,  pp   600,  cloth.     «2  ."iO. 

TODD'S  CLINICAL  LECTD  RES  o.nCERTA  IN  ACtJTB 
Diseases.  In  one  neat  octavo  volume,  of  320  pp., 
cloth      $2  SO 

STTRGES'S  INTRODHCTION  TO  THE  STUDY  OF 
CMNICAL  MEDICINE.  Being  a  Guide  to' the  In- 
ve.<tigalion  of  Disease.  In  one  handsome  12mo. 
volume,  cloth,  $1  2.j.     (Lately  I.fsned.) 

STOKE.S'  LECTURES  ON  FEVER  Edited  by  .Tohn 
Wii.MAM  MooRK,  M.  1).,  A-sistant  Physician  to  the 
(;ork  Street  Fever  Hospital.  In  one  neat  Svo. 
volume,  cloth,  *2  00      {Junt  T.oKued  ) 

THE  CYCLOPEDIA  OF  PRACTICAL  MEDICINE: 
comprising  Tieatises  on  the  Nature  and  Treatment 
of  Diseases,  MatMJa  Medica  and  Therapeutics,  Dis- 
eases of  Women  and  Childien  .Medical  .lurispru- 
deuce,  etc  etc.  By  Dunomson,  Forbids,  Twebdie, 
and  CoNOi.LV.  In  four  large  super  royal  octavo 
volumes,  of  32.U  double-columned  pnge-',  strongly 
and  handsomely  bound  in  leather,  ^ll>;  cloth,  $11. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Practice  of  Medicine).  15 


WLINT  {AUSTIN),  M.D., 

■^  Professor  of  the  Principles  and  Practice  of  Medicine  in  BeUexrue  Med.  College,  N.  Y. 

A   TREATISE    ON   THE    PRINCIPLES  AND    PRACTICE    OF 

MEDICINE;  designed  for  the  use  of  Students  and  Practitioners  of  Medicine.  Fourth 
edition,  revised  and  enlarged.  In  one  large  and  closely  printed  octavo  voluiue  of  ahout 
1100  pp.;  cloth,  $6  00  ;  orstrongly  bound  in  leather,  with  raised  bands,  $7  00.  (Late/y 
Issued.) 

By  common  consent  of  the  English  and  American  medical  press,  this  work  has  been  assigned 
to  the  highest  position  as  a  complete  and  compendious  text-book  on  the  most  advanced  condi- 
tion of  medical  science.     At  the  very  moderate  price  at  which  it  is  ofiered  it  will  be  found  one 
of  the  cheapest  volumes  now  before  the  profeesion. 
This  exc-iUenf  treatise  on  medicine  lias  acquired    His  own  clinical  studies  and   the  lafet^t  contribu- 


for  itself  in  tlie  United  States  a  reputation  similar  to 
that  enjoyed  in  England  by  the  admirable  lectures 
of  Sir  Thomas  Watson.  We  have  referred  to  many 
of  the  most  important  chupters.  and  find  the  revi- 
sion spoken  of  in  the  preface  is  a  genuine  one,  and 
that  the  author  has  very  fairly  brought  up  hi  smaller 
totheievel  oft  he  knowledge  of  the  present  day.  The 
work  has  thisgreat  recommendation,  that  it  is  in  one 
volume,  and  therefore  will  not  be  so  terrifying  to  the 
student  as  the  bulliy  volumes  which  several  of  our 
English  text-books  ofmedicine  havedeveloped  into. 
—  British  and  Foreign  Med.-Chir.  Hev.,  Jan.  1875 

It  is  of  course  unnecessary  toin  trod  uce  or  eulogize 
this  now  standard  treatise.  The  present  edition 
has  been  enlarged  and  revised  to  bring  it  up  to  the 
author's  present  level  of  experience  and  reading. 


tions  to  medical  literature  bo ih  in  this  country  and 
in  Europe,  have  received  careful  attenliou,  so  that 
some  portions  have  been  entirely  rewtitlen,  and 
about  seventy  pages  of  new  matter  have  been  ad- 
ded. —Ofiivngo  M^d  Jour.,  June,  IST.'J. 

Has  never  been  surpassed  as  a  text-book  for  stu- 
dents and  a  book  of  ready  reference  for  practiliun- 
ers.     The  force  of  its  logic,  its  simple  and  practical 
teachings,  have  left  it  without  a  rival  in  the  field 
A^.  Y.~3{ed   Record,  Sept.  l."!,  187-t. 

It  is  given  to  very  few  men  to  tread' in  the  steps  of 
Austin  Klint,  whose  sipgle  volume  on  medicine, 
though  here  and  there  defective,  is  a  masterpiece  of 
lucid  condensation  and  of  general  giasp  of  an  enor- 
mously wide  subject  — Lond.  Practitioner, Xiec.'l '. 


B 


It  is  here  that  the  skill  and  learnirg  of  the  great 
clinician  are  displayed  He  has  given  us  a  store- 
house of  medical  knowledge,  excellent  for  the  stu- 
dent, convenient  for  the  praciiiouer,  the  lesult  of  a 
long  life  of  the  most  faithful  clinical  work,  collect- 
ed by  an  eneigy  as  vgiiant  snd  systematic  as  un- 
tiring, and  weighed  by  a  judgment  no  less  clear 
than  his  observation  is  close.— ^rt'?ui:e*  vf  Medi- 
cine, Dec.  lf-79 

The  author  of  the  above  work  has  anticipated  a 
want  long  felt  by  those  for  whom  it  was  especially 
written— the  cinical  student  during  his  )i!ipilage, 
and  the  busy  practitioner.  He  has  given  to  the 
msdical  pi-ol'ession  a  very  necessary  and  u-eful 
work,  complete  in  detail,  accurate  in  observation, 
br  ef  in  statement. — St.  Lovis  Courier  of  Med., 
Oct    lS7fi. 


Y  THE  SAME  AUTHOR. 

CLINICAL  MEDICINE;    a  Systematic   Treati.se  on    the  Diagnosis 

and  Treatment  of  Diseases.  Designed  for  Students  and  Practitioners  of  Medicine.  In 
one  large  and  handsome  octavo  volume  of  795  pages;  cloth,  $4  50  ;  leather,  $5  10. 
{Noto  Reudy.) 

clearly,  and  at  the  same  time  so  concisely  as  to 
enable  the  searcher  to  traver.-e  the  entire  ground 
of  his  search,  and  at  the  same  time  obtain  all  that 
ises^eutiil,  without  plodding  through  an  intermi- 
nab'e  space. — N.  Y.  Med.  Jour..  Nov.  l.S7f) 

The  eminent  teacher  who  has  written  the  voluma 
under  consi  leration  h 'S  recognized  the  needs  of 
the  Americi.n  profession,  and  tlif  result  is  all  tlat 
we  could  wish.  The  siyle  in  whieli  it  i  wiiten  is 
peculiarly  tlie  author's ;  it  is  clear  and  forcihit  ,  and 
marked  by  those  cbaracieristies  which  hare  ren- 
dered him  one  of  the  best  writers  and  tea<'liers  this 
coun'ry  has  ever  produced.  We  have  not  space  for 
so  full  a  cons'deration  of  this  remarUable  work  as 
we  would  desire. — S.  L^niis  Clin.  Record,  Oct.  187!). 

It  is  venturing  little  to  say  Ihat  there  are  few  men 
so  well  fitted  as  I)r  Flint  to  impart  information  on 
these  last  mentioned  subj  ^cts.  and  the  present  work 
is  a  tiniply  one  as  relates  both  to  the  author's  ca- 
pacity to  undertake  it  and  the  need  lor  it  as  an 
accompaniment  to  the  miiliitude  now  issued,  in 
which  the  subject  of  treatment  is  but  little  couoid- 
ered. — Sew  Remedies,  Aov.  1S79. 


There  is  every  reason  to  believe  that  this  book 
will  be  ■well  received.  The  active  practitioner  Is 
frequently  in  need  of  some  work  Ihat  will  enable 
him  to  obtain  information  in  the  diagnosis  and 
treatment  of  cast-e  with  comparatively  little  lalior. 
Dr.   Flint   has   the  faculty   of  expressing   himfelf 


Jgr  THE  SAME  AUTHOR. 

ESSAYS    OX    COXSERVATIVR    MEDICFNE    AND    KINDRED 

TOPICS,     In  one  very  handsome  royal  12rao.  volutue.     Cloth,  $1  38.     (Just  Iss  ted.) 


H 


A R TSHORNE  ( HENR V),  M.D., 

Profesxor  of  Hygiene  in  the  Univernity  of  Pennxyl'o'inia 

ESSENTIALS  OF  THE  PRINCIPLES  AND  PRACTICE  OF  MEDI- 

CilNE.  A  htindy-book  forStudent.s  and  Practitioners.  Fourth  edition,  revised  and  im- 
proved. With  about  one  hundred  illustrations.  In  one  handsome  royal  I  2mo  volume, 
of  about  550  pages,  cloth,  $2  63;  half  bound,  $2  88.     (Lately  Issued.) 

Ag  a  handliook,  which  clearly  sets  forth  the  KssRN-  |  book,  it  cannot  be  improved  upon.  —  Chicago  Med. 
TIAI.H  of  the  Pi:i.NCiPi,i:s  and  puAcrinK  oj*  .vikdicink,     K.raininer,  Nov.  l.'i,  1874 
wedo  not  knowof  itse-iual  -  K«    M-d.  M<,nthty.     \      \vi(i,,„it  doubt  the  best  bookof  the  kind  published 

As  a  brief,  condensed,  but  comprehensive  hand-  jIn  the  Enitlish  lamtuage. — St.  Louis  Med.  ami  Surg). 

I  Journ.,  Nov.  1S7-1. 


T)A  VIS  {NA  THAN  S.), 

J-^  Prof,  of  Principles  rind  Prarlice  of  Medicine,  etc..  in  Chirngo  Med.  Cnllege. 

CLINICAL  LECTURES  ON  VARIOUS  I.VIPORTANT  DISEASES; 

being  a  collection  of  the  Clinical  Lectures  delivered  in  the  Medical  Wards  of  Mercy  Hos- 
pital, Chicago.  Edited  by  Frank  H.  Davi.s,  M  D.  Seconil  edition,  enlarged.  In  one 
handsome  royal  12mo.  volume.     Cloth,  $175.     {Lately  Issued.) 


16   Henry  C.  Lea's  Son  &  Co.'s  Publications — {Practice  of  Medicine). 
JDRISTO  WE  {JOHN  SVER),  M.D.,  F.R.C.F., 

JD  Phynicimi  andJuint  Lecturer  on  Medicinn,St.  Thomas's  Hospital. 

A    TREATISE    ON    THE    PRACTICE    OF    MEDICINE.     Second 

American  edition,  revised  by  the  Author.  Edited,  with  Additions,  by  James  H.  Hutch- 
inson, M.D.,  Physicinn  to  the  Penna.  Hospital.  In  one  hnndsome  octavo  volume  of 
neiirly  1200  pages.     With  illustrations.     Cloth,  $5  50  ;   leather,  $fi  50.      {Just  Ready.) 

In  reprinting  this  work  from  the  recent  thoroughly  revised  second  English  edition,  the 
author  has  made  such  corrections  as  seemed  advisable,  and  has  added  a  chapter  on  Insanity. 
'J'he  Editor  has  likewise  revised  his  additions  in  the  light  of  the  latest  experience,  and  the 
work  is  presented  as  reflecting  in  every  way  the  most  modern  aspect  of  medical  science,  and 
as  fully  entitled  to  maintain  the  distinguished  position  accorded  to  it  on  both  sides  of  the 
Atlantic  as  an  authoritative  guide  for  the  student,  and  a  complete  though  concise  book  of 
reference  for  the  practitioner.  Notwithstanding  the  author's  earnest  effort  at  compression, 
the  additions  have  amounted  to  about  one-tenth  of  the  ])revious  edition  ;  but  by  the  use  of  an 
enlarged  page  these  have  been  accommodated  without  increasing  the  size  of  the  volume,  while 
a  reduction  in  the  price  renders  it  one  of  the  cheapest  works  accessible  to  the  profession. 

A  few  notices  of  the  first  edition  are  subjoined. 

A  new  edilioQ  of  this  wellkDown  work,  which  '  increasei' emphasis,  repeatconceruinglhis:  "Every 
hasliad  the  advantage  of  careful  revision  not  only  i  page  isoliaracterized  by  the  utterances  of  a  though t- 
1)V  its  author  but  also  by  Dr  Hutchinson,  than  I  ful  man.  What  has  been  said,  has  been  well  said, 
w'liom  there  is  no  one  in  this  country  better  fitted  |  and  the  book  is  a  fair  reflex  of  all  that  is  certainly 
for  the  task. Pltila.  Med.  Tinfif,  3a,n. 'A,  \%%Q.  \  known  on   the  subjects  considered."— 0/i<9    Med. 

The  popularity  of  the' work  depends,  no  doubt,     Recorder,  Jan.  7,  ISSO. 
upon  the  clear  and   incisive  way  in   which   it  is  I      This  is  not  only  one  of  the  latest  and  most  corn- 
written,  and  the  attention  to  details  likely  to  occur  ;  prehensive  works  out  on   the  general   subject   of 
in  practice,  ratlier  than  the  discussion  of  questions  ]  Theory  and  Practice  of  Medicine,  but  it  is  unques- 
(jf  theory.— A'eJt)  iZe/iiedi'es,  Jan.  ISSO.  tiouably  one  of  the  best.— So.  Med.  Practitiontr, 

What  we  said  of  the  first  edition,  we  can,  with     J^"^-  ^^SO. 


w 


'OODBURY  [FRANK),  M.D., 

Phyxirian  to  the  German  Hospital,  Philadelphia,  late  Chief  Assist,  to  Med.  Clinic,  Jeff.  College 

A    HANDBOOK   OF    THE   PRINCIPLES  AND   PRACTICE    OF 

Medicine  •   for  the  use  of  Students  and  Practitioners.     Based  upon  Husband's  Handbook 
of  Practice.     In  one  neat  volume,  royal  12mo.      {In  Press.) 


fJABERSHON  [S.  0.).  M.D. 

-*-'*-  Senior  Phy.s-ician  to  and  late  Lecturer  on  the  Principles  and  Practice  of  Medicine  at  Gtty's 

Hosjntnl,  tin. 

ON  THE  DISEASES  OF  THE  ABDOMEN,  COMPRISING  THOSE 

of  the  Stomach,  and  other  parts  of  the  Alimentary  Canal,  (Esophagus,  Cgecum,  Intes- 
tines, and  Peritoneum.     Second  American,  from  the  third  enlarged  and  revised  Eng- 
lish edition.     With  illustrations.     In  one  handsome  octavo  volume  of  over  500  pages. 
Cloth,  $3  50.      {Now  Ready.) 
We  can  do  very  little  to  add  to  the  favorable  re-  i  of  information,  systematically  arranged,  on  all  dis- 
cpption  which  has  already  been  given  by  the  medi- !  eases  of  the  alimentary  tract,  from  the  mouth  to  the 
cal  press  of  the  world  to  this  well  known  treatise    '  rectum      A  fair  proportion  of  each  chapter  is  devot- 
We  commend  to  all  practitioners  a  careful  perusal  ,  ed  to  symptoms,  pathology,  and  therapeutics.    The 
of  Dr.  Habershon's  work    More  especially,  we  draw  1  present  edition  is  fuller  than  former  ones  in  many 
attention  to  the  number  of  inte.stinal  diseases  re-    particulars,  and  has  been   thoroughly  revised  and 
corded  in  its  pages,  cases  of  extreme  interest  cliui-  i  amended  by  the  author.    Several  new  chapters  have 
cally  and  pathologically.    This  careful  record  shows    been  added",  bringing  the  work  fully  up  to  the  times, 
thut  the  work  is  mi  compilation,  but  a  careful  exposi-  '  and  making  it  a  volume  of  interest  to  the  practitioner 


tion  of  the  author's  personal  experience.  —  Canadian 
Med.  and  Surg.  Journ.,  May,  1879. 

This  valuable  treatise  on  diseases  of  the  stomach 
and  abdon  en  has  been  out  of  print  for  several  years, 
and  is  therefore  not  so  well  known  to  the  profe.ssion 
as  it  deserves  to  be.     It  will  be  found  a  cyclopaedia 


in  every  field  of  medicine  and  surgery.  Perverted 
nutrition  is  in  some  form  associated  with  all  diseases 
we  have  to  combat,  and  we  need  all  the  light  that 
can  be  obtained  on  a  subject  so  broad  and  general. 
Dr  Habershon's  work  is  one  that  every  practilioner 
should  read  and  study  lor  himself. — iV.  Y.  Med. 
Journ.,  April,  1879. 


F 


'OTHERGILL  {J.  MILNER),M.D.  Edin.,  M.R.C.P.  Land., 

As-if.  Phys.  to  the  West  Lond.  Hosp.  :  As.'it.  Phy.'<.  to  the  City  of  Lond.  lfosp.,etc. 

THE  PRACTITIONER'S  HANDBOOK  OF  TREATMENT;  Or,  the 

Principles  of  Therapeutics.     In  one  very  neat  octavo  volume  of  about  650  pages  :  cloth, 
$4  00.     {Now  Ready.) 
Our  friends  will  find  tliis  a  very  readable  book;  and  .lie  knew  how  suggestive  and  helpful  it  would  be  to 


that  it  shedsliglii  ujion  every  theme  it  touches, causing 
the  practitioner  to  feel  more  certain  of  his  diagnosis  in 
difficult  cases.  We  confidently  commend  the  work  to 
our  readers  as  one  worthy  of  careful  perusal.  It  lights 
the  way  over  obscure  and  difficult  passes  in  medical 

practice.    The  chapter  on  the  circulation  of  the  blood 

is  the  most  exliaustiveiind  instructive  to  be  found.   It  !  nVateriaiVorthouglUabound  throughout.- .Boston  J/erf. 
is  a  book  every  practitioner  needs,  and  would  have,  if  ]  ^^^  ^„,.p  Journal,  Mar.  8, 1S77. 


him.— <S'(.  Louis  Med.  and  Surg.Jotirn.,  April,  1877. 

We  heartily  commend  his  book  to  themedical  student 
as  an  honest  and  intelligent  guide  through  the  mazes  of 
therapeutics,  and  assure  the  practitioner  who  has  grown 
gray  in  the  harness  that  he  will  derive  pleasure  and  in- 
struction from  its  perusal.     Valuable  suggestions  and 


-DT  THE  SAME  AUTHOR. 

THE  ANTAGONISM  OF  THERAPEUTIC  AGENTS,  AND  WHAT 

IT  TEACHES.    Being  the  Fotbergillian  Prize  Essay  for  1878.    In  one  neat  volume,  royal 
12mo.  of  156  pages;  cloth,  $1  00.      {Just  Ready. \ 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Practice  of  Medicine).    17 


J>EYNOLDS  (J.  RUSSELL).  M.D., 

-'-*'        Prof,  of  the  Principles  and  Practice  of  Medicine  in  Univ.  College,  London. 

A  SYSTEM  OF  MEDICINE,  with  Notks  and  Additions  by  Hknry  Habts- 

HORNB,  M.D.,  late  Professor  of  Hygiene  in  the  University  of  Penna.      In  three  large  and 
handsome  octavo  volumes,  containing  ahout  3000  closely  printed  double-columned  pages,, 
with  numerous  illustrations.     Sold  onlj'  by  subscription.     Price  per  vol  ,  in  cloth,  $5.00  ; 
in  leather,  $6.00. 
Volume  I.    {just  ready)  contains  General  Diseases  and  Diseases  or  the  Nervous  System. 
Volume  II.    {jvst  rendy)  cont.nins  Diseases  op  Respiratory  and  Circulatory  Systi^ms. 
Volume  III.  [prepariiig  for  early  jniblicatioii)  will  contain  Diseases  op  the  Digestive  and 
Blood  Glandular  Systems,  op  the  Urinary  Organs,  of  the  Female  Reproductive 
System,  and  of  the  Cutaneous  System. 

Reynolds's  System  or  Medicine,  recently  completed,  has  acquired,  since  the  first  appearance 
of  the  first  volume,  the  well-deserved  reputation  of  being  the  work  in  which  modern  British 
medicine  is  presented  in  its  fullest  and  most  practical  form.  This  could  scarce  he  otherwise  in 
view  of  the  fact  that  it  is  the  result  of  the  collaboration  of  the  leading  minds  of  the  profession, 
each  subject  being  treated  by  some  gentleman  who  is  regarded  as  its  highest  authority — as  for 
instance.  Diseases  of  the  Bladder  by  Sir  Henry  Thompson,  Malpositions  of  the  Uterus  by 
Graily  Hewitt,  Insanity  by  Henry  Maudsley,  Consumption  by  J.  Hughes  Bennet,  Dis- 
eases of  the  Spine  by  Char-les  Bland  Radclipfe,  Pericarditis  by  Francis  Sibson,  Alcoholism 
by  Francis  E.  Anstie,  Renal  Affections  by  William  Roberts,  Asthma  by  Hyde  Salter, 
Cerebral  Affections  by  fc[.  Charlton  Bastian,  Gout  and  Rheumatism  by  Alfred  Baring  Gar- 
rod,  Constitutional  Syphilis  by  Jonathan  Hutchinson,  Diseases  of  the  Stomach  by  Wilson 
Fox,  Diseases  of  the  Skin  by  Balmanno  Squire,  Affections  of  the  Larynx  by  Morell  Mac- 
kenzie, Diseases  of  the  Rectum  by  Blizard  Curling,  Diabetes  by  Lauder  Brunton,  Intes- 
tinal Diseases  by  John  Syer  Bristowe,  Catalepsy  and  Somnambulism  by  Thomas  King  Cham- 
bers, Apoplexy  by  J.  Hughlings  Jackson,  Angina  Pectoris  by  Professor  Gairdner,  Emphy- 
sema of  the  Lungs  by  Sir  William  Jenner,  etc.  etc.  All  the  leading  schools  in  Great  Britain 
have  contributed  their  best  men  in  generous  rivalry,  to  build  up  this  monument  of  medical  sci- 
ence. St.  Bartholomew's,  Guy's.  St.  Thomas's,  University  College,  St  Mary's  in  London,  while 
the  Edinburgh,  Glasgow,  and  Manchester  schools  are  equally  well  represented,  the  Army  Medical 
School  at  Netley,  the  military  and  naval  services,  and  the  public  health  boards.  That  a  work 
conceived  in  such  a  spirit,  and  carried  out  under  such  auspices  should  prove  an  indispensable 
treasury  of  facts  and  experience,  suited  to  the  daily  wants  of  the  practitioner,  was  inevitable,  and 
the  success  which  it  has  enjoyed  in  England,  and  the  reputation  which  it  has  acquired  on  this 
side  of  the  Atlantic,  have  sealed  it  with  the  approbation  of  the  two  pre-eminently  practical  nations. 

Its  large  size  and  high  price  having  kept  it  beyond  the  reach  of  many  practitioners  in  this 
country  who  desire  to  possess  it,  a  demand  has  arisen  for  an  edition  at  a  price  which  shall  ren- 
der it  accessible  to  all.  To  meet  this  demand  the  present  edition  has  been  undertaken.  The 
five  volumes  and  five  thousand  pages  of  the  original  will,  b}'  the  use  of  a  smaller  type  and  double 
C(dumn.-!,  be  compressed  into  three  volumes  of  about  three  thousand  pages,  clearly  and  hand- 
somely printed,  and  offered  at  a  price  which  will  render  it  one  of  the  cheapest  works  ever  pre- 
sented to  the  American  profession. 

But  not  only  will  the  American  edition  be  more  convenient  and  lower  priced  than  the  English; 
it  will  also  be  better  and  more  complete.  Some  years  having  elapsed  since  the  appearance  of  a 
portion  of  the  work,  additions  will  be  required  to  bring  up  the  subjects  to  the  existing  condition 
of  science.  Some  diseases,  also,  which  are  comparatively  unimportant  in  England,  require  more 
elaborate  treatment  to  adapt  the  articles  devoted  to  them  to  the  wants  of  the  American  physi- 
cian ;  and  there  are  points  on  which  the  received  practice  in  this  country  differs  from  that 
adopted  abroad.  The  supplying  of  these  deficiencies  has  been  undertaken  by  Henry  Harts - 
HORNE,  M.D.,  late  Professor  of  Hygiene  in  the  University  of  Penns^dvaniii,  who  will  endeavor 
to  render  the  work  fully  up  to  the  day,  and  as  useful  to  the  American  physician  as  it  has  proved 
to  be  to  his  English  brethren.  The  number  of  illustrations  will  also  be  largely  increased,  and 
no  effort  will  be  spared  to  render  the  typographical  execution  unexceptionable  in  every  respect. 
The  first  and  second  volumes  are  now  ready,  and  the  completion  of  the  whole  may  be  expected 
shortly. 

Keally  too  much  praise  can  scarcely  be  given  to     honse  of  information,  in  regard  to  so  many  of  the 


tliis  uoble  boolc.  It  is  a  cyclop.eiiia  of  ineciicine 
written  by  Home  of  the  bi^st  men  of  Europe.  It  is 
full  of  useful  inlorination  Hnch  as  one  lluds  freiiueot 
Deed  of  in  one's  dnily  work  ;  for  no  duo  head  caa 
jiosHibly  carry  all  the  knowledge  one  needs  in  gen- 
eral practice,  and  one  mast  refer  somi'tiines  to  one'« 
librar;-.  A.s  a  book  of  reference  it  i.s  invaluable.  It 
i.s  up  with  llie  times.  It  is  clear  and  concentrated 
in  i-tyle,  and  its  form  is  worthy  of  its  famous  pub- 
lisherH, — Lfjuiffville  Mtd   News,  Jan.  .il,  ISSO. 

"Reynolds'  System  of  Medicine"  is  Ju'tly  con- 
sidered the  most  popular  work  ou  the  principles  and 
practice  of  medicine  in  the  English  language  The 
contributors  to  this  work  are  geulleineu  of  well- 
known  reputation  ou  both  sides  of  the  Atlantic. 
Each  gentleman  has  Hiriven  to  make  his  part  of  the 
work  as  practical  as  pos-ible,  and  the  information 
contained  is  such  as  is  needed  by  the  busy  practi- 
ti  )uer.  — 5<.  Louin  Med.  and  Hurg.  Joum.,  Jan.  20, 
ISSO. 

Dr.  Hartshorne  has  made  ample  additions  and  re- 
visions so  far,  all  of  which  give  increased  value  to 
the  volume,  and  render  it  more  useful  to  the  Ameri- 
can practitioner.  There  is  no  volnme  in  English 
medical  lite.ature  more  valuable,  and  every  pur- 
chaser will,  on  becoming  familiar  with  it,  congrat 
ulate  himself  ou  the  possesbion  of  this  vast  siore- 


subjects  with   which  he  should  be  familiar. — Gait- 
lard'n  Med.  Journ.,  Feb.  IS^O. 

There  is  no  medical  work  which  we  have  in  times 
past  more  freipieutly  and  fully  consulted  when  per- 
lilexed  by  doubts  as  to  treatment,  or  by  having  un- 
usual or  apparently  inexplicable  symptoms  jire- 
sented  to  us  than  "Keynolds'  System  of  Medicine." 
.\mong  Its  contriluitors  are  genllemnn  who  are  as 
well  known  by  reputation  upon  this  side  of  the 
.\tliintic  as  in  Groat  Britain,  ami  whose  right  to 
speak  with  authority  upon  the  snbji'cts  about 
which  they  have  written,  is  recognized  the  world 
.)ver.  They  have  eviilenily  striven  to  make  their 
essays  as  practical  as  possible,  and  whilo  these  are 
sulliciently  full  to  entitle  them  to  the  name  of 
monographs,  they  are  not  loaded  down  with  such 
an  amount  of  detail  as  to  render  thorn  wearisome 
to  the  genernl  reader.  In  a  word,  they  contain  just 
that  kind  of  information  which  the  l>usy  practitioner 
freiiuently  finds  himself  in  ueoil  of.  In  order  that 
any  deficiencies  may  be  supplied,  Ihe  publishers 
have  committeil  the  preparation  of  the  book  for  the 
press  to  Dr.  Henry  Hartshorne,  whose  judicious 
notesdlstribnled  throughout  the  volume  affordjabnu- 
dant  evidence  of  tho  thoroughness  of  i  he  revision  to 
which  he  has  subjected  it. — Am.  J(,iir.Mtd.  Sciences, 
Jan.  18S0. 


18     Henry  C.  Lea's  Son  &  Co.'s  Publications — (Prac.  of  Med.,  &c.). 


PINLAYSON  [JAMES],  M.D., 

Phi/.sician  ar>d  Lecturer  on  Clinical  Medi"ine  in  fht  Glasgow  Western  Infirmary,  etc. 

CLINICAL  DIAGNOSIS;  A  Handbook  for  Students  and  Prac- 
titioners of  Medicine.  In  one  handsome  12uio.  volume,  of  546  pages,  with  85  illustra- 
tions.    Cloth,  $2  63.      (Jitit  Read]/.) 


treat.  There  is  a  profusina  of  illustrations  to  illus- 
tr-ite  subjects  under  discussioa.  The  applicatii'n  of 
electricity,  and  iustrurnenlsof  preci.sion  in  diaguosis, 
is  fnlly  discussed.  This  book  is  all^ood.  We  coni- 
iiiend  it  to  all  students  and  practitioners  of  medicine 
as  a  work  worthy  of  a  place  in  theirlibraries. —OAto 
Med.  Recorder,  Dec.  1S7S. 

This  in  one  of  the  really  usieful  books  It  is  attrac- 
tive from  preface  to  the  final  page,  and  ought  to  be 
given  a  place  on  every  office  table,  becau.«e  it  contains 
in  a  condensed  form  all  that  is  valuable  in  seraeiology 
and  diag'iostics  to  be  found  in  bulkier  volumns,  and 
because  in  its  arrangement  and  complete  i  ndex,  it  is 
unusually  convenient  for  quick  reference  in  any 
emergency  that  may  come  upon  the  busy  practitioner. 
— N.  0.  Med.  Journ.,  Jan.  1879. 


The  book  is  an  excellent  one,  clear,  concise,  conve- 
nient, practical.  It  is  replete  with  the  very  know- 
ledge the  student  needs  when  he  quits  the  lecture- 
room  and  the  laboratory  for  the  ward  and  sick-room, 
and  does  not  lack  in  information  that  will  meet  the 
wants  of  experienced  and  older  men.— Phila.  Med. 
Times,  Jan.  4,  1S7!). 

The  aim  of  the  author  is  to  teach  a  student  and 
practitioner  how  to  examine  a  cas.  .so  as  to  use  "all 
his  knowledge"  in  ariiviug  at  a  diagnosis.  All  the 
various  symptoms  of  the  several  systems  are  grouped 
together  in  such  a  manner  as  to  m-tke  their  relations 
to  a  final  diagnosis  clear  and  easy  of  apprehension. 
This  work  lias  been  done  by  men  of  large  experience 
and  trained  observation,  who  have  been  long  recog- 
nized as  authorities  upon  the  subj>-cis  which  they 

TJA MIL rO .\'  [ALLAN  MrLANE)TM.D~ 

Attending  Phj/.ncian  at  the  Honpitnl/or  Epileptics  and  Pnralplics,  BlacliWelVs  Island,  N.  7., 
a  lid  at  the  Oui-l'alients'  Deportraeiit  of  the.  Nerr  York  Ho.fpitol. 

NEPvVOUS  DISEASES  ;TIIEIR  DESCRIPTION  AND  TREATMENT. 

In  one  handsome  octavo  volume  of  512  pages,  with  53  illus. ;  cloth,  $3  50.     (Now  Ready.) 


This  is  unquestionably  the  best  and  most  com 
plete  text-book  of  nervous  disea-es  that  has  yet  ap- 
peared, and  were  international  jealousy  in  scientific 
affairs  at  all  possible,  we  might  be  excused  fir  a 
feeling  of  chagrin  that  it  should  be  of  American 
parentage.  This  work,  however,  has  been  performed 
in  New  York,  and  has  been  so  well  performed  that 
no  room  is  left  for  anything  but  commendation. 
With  f  reat  skill,  Dr.  Hamilton  has  presetted  lo  his 
readers  a  succinct  and  lucid  survey  of  all  that  is 
known  of  the  pathology  of  the  nervous  system, 
viewed  in  the  light  of  the  most  recent  researches. 
From  the  preliminary  description  of  the  methods  of 
examination  and  study,  and  of  the  instruments  of 
precision  employed  in  the  in vestigatii'n  of  nervous 
diseases,  up  till  the  final  collection  of  fiirinulje,  t  e 
book  is  eminently  practical.  —  Brain.  Loudon,  Oct. 
1878. 

The  author  tells  us  in  his  preface  that  it  has  been 
his  object  to  produce  a  concise,  praciical  book,  and 
we  think  he  lias  been  successful,  considering  tlie  ex- 
tent of  tiie  suliject  which  he  has  undertaken.  In 
fact,  it  is  more  exieusire  than  the  title  properly  or 
accurately  indicates,  embracing— besides  what  are 
usually  regarded  as  nervous  diseases — inflammatory 


affections,  both  acute  and  chronic,  hemorrhages  and 
tumors  of  the  cerebrum  and  cerebellum,  medulla 
oblongata,  spinal  cord  and  nerves,  with  thrombosis 
and  embolism  of  the  arteries^  sinuses,  and  veins. 
The  reader  may  therefore  expect  information,  more 
or  less  full  and  satisfactory,  on  almost  every  point 
connected  with  the  nervous  system.  We  have  no 
hesitation  in  saying  that  reliauce  may  be  placed  on 
Dr.  Hamilton's  coDscientious  performance  of  his  self- 
assigned  task,  on  his  soundness  of  judgment,  and 
freedom  from  empiricism. — Edinburgh  Med.  Journ., 
Oct.  1S7S. 

From  a  very  careful  examination  of  the  whole 
work,  we  c  i'  j  u-^tly  s^y  that  the  author  has  not  only 
clearly  and  fully  treated  of  dingnosis  and  treatment, 
but.  unlik-'  most  works  of  this  class,  it  is  very  com- 
prehensive in  regard  to  etiology,  and  exposes  the 
pathology  of  nervous  disease.s  i  n  the  light  of  the  very 
latest  experiinents  tnd  discoveries  The  drawings 
are  excellent  and  well  selected.  After  this  careful 
revision,  we  can  heartily  recommend  this  work  to 
students  and  general  practitioners  in  particular  as 
being  a  full  expo-ition  of  aiseases  of  the  nervous  sys- 
tern,  their  pathology  and  treatment,  to  date.— jY.  Y. 
Med.   Record,  Aug.'s,  ISTS, 


o 


'HARCOT  [J.  M.]. 

Profes-forto  the  Faculty  of  Med.  Paris,  Phys.  to  La  Salpetriire,  etc. 

LECTURES  ON  DISEASES  OF  THE  NERVOUS  SYSTEM.  Trans- 
lated from  the  Second  Edition  by  Gkokob  Sigerson,  M.D.,  M.Ch.,  Lecturer  on  Biology, 
etc.,  Cath.  Univ.  of  Ireland.  With  illustrations.  1  vol.  8vo.  of  288  pages.  Cloth,  $1  75. 
(Just  Ready.) 


CLINIOAL  OBSERVATIONS  ON  FUNCTIONAL 
NERVOUS  DISOKUEKS  BvC.  HandfieldJones. 
M  U.,  Physician  to  St.  Mary's  Hospital,  &c.  Sec- 


ond America  r  Edition.    In  one  handsome  octavo 
▼olumeof  :U8  pages, cloth,  iJiH  25. 


mX  [  TILBURF),  M.D.,  F.R.C.P.,  and  T.  C.  FOX,  D.A.,  M.R.C.S., 

Phi/siruin  to  the  Department  for  Skin  Diseases,  University  College  Hospital. 

EPITOME  OF  SKIN  DISEASES.     WITH  FORMULAE.     For  Stu- 

DENTS  AND  Practitionkrs .  Second  edition, thoroughly  revised  nnd  greatly  enlarged.  In 
one  very  handsome  12mo.  volume  of  216  pages.  Cloth,  $1  38.  (.Just  Ready) 
The  names  of  the  authors  are  quite  sufficient  to  ,  The  present  edition  of  the  Epitome  considerably 
commend  this  book.  Dr.  Tilbury  Fox  being  w«*l  ,  exceeds  in  size,  and  surp.isses  in  use,  its  predeces- 
known  as  occupying  a  place  in  the  front  rank  of  i  por.  The  work  is  ceriainly  a  valuable  addition  to 
dermatologists  of  the  dny.—  Canadian  Journal  of  '  the  '•  handy  v  >lu me"  department  of  medical  litera- 
3ted.  Sri.,  May,  1S78.  tnre.  — The  Med.  Bulletin,  May,  1S7S. 


WILSON'S  STUDENT'S  BOOK  OF  CUTANEODS 
MEDICINE  and  Dipeasbs  of  the  Skin.  In  one 
very  handsome  royal  12mo.  volume.    $3  .10. 


HILLIER'S  HANDBOOK  OF  SKIN  DISEASES,  for 
Students  and  Practitioners.  Second  Am.  Ed.  In 
one  royal  12mo.  vol.of  358  pp.  With  illustrations. 
Cloth,  $2  25. 


if' 


ORRLS  {MALCHOM).  M.D.  .  c  ,    , 

Joint  Lecturer  on  Dermatology,  St.  Mary's  Hospital  Med.  .School. 

SKIN  DISEASES,  Incliidina  their  Definitions,  Symptoms,  DiagnosiiS, 

ProenoMS,  Morbid  Anntrmy,  and  Treatment.    A  Manual  for  Students  and  Practitioners 
In  one  12mo.  volume  of  over  300  pages.     With  illustrations.     Cloth,  $1  75.     (bhorty) 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Dis.ofthe  Chest,  &c.).   19 
JgROWN  [LENNOX),  F.R.G.S.  Ed., 

Senior  Surgeon  tothe  Gentrnl  London  Throat  and  Ear  HogpitaJ,  etc., 

THE  THROAT   AND  ITS  DISEASES.     With  one  hundred  Typical 

Illustrations  in  colors,  and  fifty  wood  engravings,  designed  and  executed  by  the  author. 
In  one  very  handsome  imperial  octavo  volume  of  361  pages  ;  cloth,  $5  00.  {Now  Ready.) 
The  author's  rare  artistic  skill  h;is  been  utilized  j  are  unusually  nccurate.     In  coaclusiou,  we  recom- 


in  the  production  of  one  hundred  lieaiitifal  illustra 
lions  in  colors,  the  very  best  of  the  kind  we  have 
seen,  and  which  have  been  distributed  in  ten  plates. 
Fifty  wood  engravings,  designed  and  execnted  by 
the  author,  appear  in  the  body  of  the  work — these 


mend  this  beautiful  volume  as  an  acceptable  addi- 
tion to  the  library  of  those  engaged  in  tbe  treatment 
of  diseases  of  the  throat.— iV.  Y.  Med.  Record,  Nov. 
9,  1S7S. 


UEILER  (CAEL),  M.D., 

^  Lecturer  on  Laryuffo.'ied'py  at  the  Univ.   of  Penna  ,   Chief  of  the  Throat  Di.tpennary  at  the 

Univ.  Hospital,  Phila.,  etc. 

HANDB(30K  OF  DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OP 

THE    THROAT   AND    NASAL   CAVITIES.      In   one  handsome  royal  12mo.  volume, 

of  156  pages,  with  35  illustrations;   cloth,  $1.      {Just  Ready.) 

We  most  heartily  commend  this  book  as  showing  I      A  convenient  little  handbook,  cl>?ar.  concise,  and 

found  judgment  in  practice,  and  peifect  farniliariiy  j  accurate  in  its  method,  and  ad mira lily  fulfilling  its 

with   the  literature  of  tlie  spec  alty  it  so  ably  epi-  j  purpo.-e  of  bringing  tbe  subject  of  which  it  treats 

tomizes. —  Philada.   3I,.d.  Times,  Ja[j  o,  1S79.  j  wilhin    the   comprehension   of  the  general  practi- 

'  lioner. — N.  C.  Med.  Jour.,  June,  lii79. 

PLINT  (AUSTIN),  M.D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevrie  Hospital  Med.  College,  N.  T. 

PHTHISIS:  ITS  MORBID  ANATOMY,  ETIOLOGY,  SYMPTOM- 
ATIC EVENTS  AND   COMPLICATIONS,  FATALITY  AND  PROGNOSIS,  TREAT- 
MENT, AND  PHYSICAL  DIAGNOSIS  ;   in  a  series  of  Clinical  Studies.     By  Austin 
Flint,  M.D.,  Prof,  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  H   spital  Med. 
College,  New  York.     In  one  handsome  octavo  volume  :  $3  50.      {Lutely  Issued.) 
This  book  contains  an  analysis,  in  the  author's  lucid  I  mend  the  book  to  the  perusal  of  all  interested  in  the 
style,  of  the  notes  which  he  lias  made  iti  several  hun-     study  of  this  disease. — Boston  Med.  and  Surg  Journal, 
dred  cases  in  hosiiital  and  private  practice.     We  com-  j  Feb.  10,  1S76. 

or   THE  SAME   AUTHOR. 

A  MANUAL  OF  PERCUSSION  AND  AUSCULTATION;   of  the 

Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.    In 
one  handsome  royal  12mo.  volume:  cloth,  $1   76.     {Just  Issued.) 

J>Y  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OF  DISEASES  OF  THE  HEART.     Second  revised  and  enlarged 

edition.     In  one  octavo  volume  of  660  pages,  with  a  plate,  cloth,  $4. 

Dr.  Flint  chose  a  difficult  subject  for  his  lesearche*,  :  and  clearest  practical  treatise  on  those  subjects,  and 

»nd  has  shown  remarkable  powers  of  observation  |  jhould  be  in  the  hand.s  of  all  practitioners  and  stu- 

and  reflection,  as  well  as  great  industry,  in  his  treat-    ients.  It  is  a  credit  to  American  medical  literature. 

ment  of  it.    His  book  mtisi  be  considered  the  fullest  i  —Amer.  Journ.  of  the  Med.  Sciences,  July,  1860. 

JOY  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  596  pages,  cloth,  $4  60.       

WII.LIAM.SS  PULMONARY  CONSUMPTION;  its 
Nature,  Varieties,  and  Treatment.  Wiih  an  An- 
alysis of  One  Thousand  Cases  to  exemplify  its 
duration.  In  one  neat  octavo  volume  of  about 
.3.'(ii  pages  ;   cloth,  ■{(2  .10. 

&LAI)E  ON  DIHHTIIERIA;  its  Nature  and  Treat- 
ment,  with  an  account  of  the  History  of  its  Pre- 
valence in  various  Countries  Second  and  revised 
edition.  lu  one  neat  royal  12mo.  volume,  cloth, 
*1  2.5. 

WALSHE  ON  THE  DISEASES  OF  THE  HEART  AND 
GKEAT  VESSELS.  Third  American  Edition.  In 
1  vol.  Svo.,  420  pp.,  cloth,  ijci  00. 

LECTURE.S  ON  THE  DISEASES  (iF  THE  STOMACH. 
With  an  Introduction  on  its  Anatomy  and  Physio- 
logy. By  Wii,i,iA.M  liKiNro.v,  M  D.,  F  K  S  From 
the  second  and  enlarged  London  edition  .  With  il- 
lustrations on  wood  In  one  handsume  octavo 
volume  of  about  .SOO  pages:  cloth,  ^:i  26. 

CHAMBKIl.S'S  .MANUAL  OK  DIET  AND  REGIMEN' 
IN  HKALTII  ANIJ  SI('lvXE<S.  In  one  handsome 
octavo  volume.     Cloth,  $2  7J. 


LA  ROCHE  ON  PNEUMONIA.  1  vol.  8to.,  cloth* 
of  .OOO  pages.     Price,  $:■!  0(i. 

LINCOLN'S  ELECTRO-THERAPEUTICS;  a  Concise 
Maunal  of  Medical  Electricity.  In  one  very  neat 
royal  12mo.  volume,  cloth,  with  Illustrations, 
*1  .30. 

FULLER  ON  DISEASES  OF  THE  LUNGS  AND  AIR- 
PASSAGES.  Their  Pathology,  Physical  Diagnosis, 
Symptoms,  and  Treatment.  From  the  second  and 
revised  English  edition.  In  one  handsome  ocatvo 
voliune  of  about  ."lOO  pages  :  cloth,  i|i:^  oO. 

SVIITH  ON  CONSUMPTION  ;  ITS  EARLY  AND  RE- 
MKDI  ABLE  STAGES.    1  vol.  fivo. ,  pp   254     t22r. 

BASIIAM  <1N  RE^f  AL  DISEASES:  a  Cliuical  Guide 
to  their  Diagnosis  and  Treatment.  With  Illustra- 
tions   In  one  12mo.  vol   of  :W^  pages,  clo'h,  if2  00. 

LECTURES  ON  THE  STUDY  OF  FEVER.  By  A. 
Hdd.son,  M.D.,  M.R.I. A.,  Physician  to  the  Meath 
Hospital      In  one  vol,  Svo.,  cloth,  *2  .'iO. 

A  TREATISE  ON  FEVER.  By  Robkkt  D.  Lyons, 
KCC.  Inone  octavo  volume  of  362  pages,  cloth, 
!il2  25. 


20 


Henry  C.  Lea's  Son  &  Co.'s  Publications-(  Venereal  Disen^es,  <&c.). 


nUMSTEAD  {FREEMAN  J.),  M.D.,LL.D.,  ~  ' 

ProfMsnr  of  Venereal  Diseases  at  the  Col.  of  Phys.  and  Srtrg. ,  New  YorT<  &c 

THE  PATHOLOGY  AND   TREATMENT  OF  VENEREAL 


BIS- 


rpti^Sf  ■    ^"'^  "       f         '^'11  *'  Of  recent  investigations  upon  the  subject.    Fourth  edition 

YorT    Prof      ?T^   'n""'"  ^1'\'t^'   co-operation   of  R.  W.  T.aylor,  M.D  ,  of  New 

1     '        .  o.r" ^  Dermatology  ,n    the  Univ.  of  Vt.      In  one  large    and  handsome  oo  avo 

volume  01  835  pages,  w.th  138  illustrations.   Cloth,  $4  75  ;  leather,  $5  75     (Jv7 Ready) 

This  work    on   its  f.r.^t  appearance,  inn^ediately  took  the  position  of  a  standard  authority  on 

ts    ubject  wherever  file  language  is  spoken,  and  the  success  of  an   Italian  tran.rt  on"  hows 

hat  ,t  IS  regar.led  with  equal  f  ,vor  on  the  Continent  of  Europe.  In  repeated  editions  the  nuthor 

abored  sedulously  to  render  it  more  worthy  of  its  reputation,  and  in   the  present  revM^n   no 

a,ns    have    been  spared  to  perfect  it  as  for  as  possible.     Several  ve.rs  hL'ng  eCed  .ince 

he  publication  of  the  th;rd  edition,  much  material  has  been  accunuilated  dnril,.    he  Interval 

by  the  industry  of  syph.lologists,  and  new  views  have   been  enunciated.     Al     thi      so  fa     a 

confirmed  by  observation  and   experience,  has  been  incorporated;    many  portion.,  of  the  voume 

been  rewritten    the  series  of  illustrations  has  been  enlarged  and  improvld.  and  the  whok  ma v 

"^L  7^::^:^^:s^:a£::^  -  .nding^Lan -.r^t- ^t^^  ^;S'::i^t -sis 

era  work  devoted  exclii.sively  to  the  discussion  of 
veuei-eal  diseases.  It  was  aeeded,  aud  will  he  cor- 
diaUv  welcomed  by  all  wlio  desire  to  keep  abreast 
with  the  times  iu  their  knowledge  of  these  subjects 
It  IS  cue  of  the  few  really  good  books  needed  hy 
every  practitioter  of  medicine  or  surgery  jrhether 
he  be  a  general  practitijuer  or  specialist.'^ i)«iro« 
Lancet,  December,  1879. 

Dr.  Bumsfead'ssnccessfullaboTS  "Dtitle  him  now 
to  rank  pre-eminently  as  «/te  authority  in  this  couu 
try  on  venereal  diseases.  But  not  only  does  this 
(act  make  his  present  treatise  of  interest  to  practi- 
tioners; the  book  is  fully  abreast  with  present 
literature  on  the  subject  of  wliich  it  treats  is  ex- 
tremely practical  in  descriptions  of  the  severnl 
venereal  diseases  and  modes  of  treatment  and  heure 
should  be  in  every  doctor's  library.— Fa.  Med. 
Muntkl.y,  December,  1S79. 


However  valuable  the  previous  eJition^  have  been 
the  present  is,  to  our  thinking,  decidedly  of  more 
worth.  An  air  of  completeness— of  having  had  gar- 
nered into  its  pages  all  the  best  fruit  of  the  world's 
experience  and  lesearch  upon  the  subiect  of  which 
It  treats— has  been  given  to  the  book,  without  in 
any  way  detrncting  from  the  peculiarly  practical 
value  ot  previous  editions.  Ncne  the  less  clinical, 
the  treatise  seems  niucli  more  cosmopolitan.  The 
P'isses.sion  of  old  editions  will  be  no  excuse  to  the 
progressive  physician  for  not  purchasing  this  edi- 
tion, and  we  pred-ct  for  it  a  very  speedy  sale.  We 
coiigratnlate  Dr.  Bumstead  on  the  wisdom  which 
led  to  the  selection  of  Ur.  Taylor  as  colleague,  and 
we  sincerely  congratulate  the  two  coworkers  npon 
the  results  of  th«ir  la.bor.— Philadelphia  Medical 
Times,  Dec.  6,  1S79. 

As  it  now  stands,  this  is  the  only  complete  niod- 


and         T)UMSTE AD  {FREEMAN  J.), 

■*-'       Professor  of  Venerea  I  Diseases  in  the  College  of 


(lULLERIER  {A.), 

V^        Surgeon  to  the  Hdpitaldu  Midi.  JL^       Professor  of] 

A  -VT     »  mT    1  r>.    ^^  Physicians  and  Surgeons.  N.  Y. 

AN  ATLAS  OF  VENEREAL  DISEASES.  Tran.slnted  and  Edited  by 

Jl^lyi  ^'^"'^'^^.^?-  In  one  large  imperial  4to.  volume  of  328  pages,  double-columns 
w  th  26  plaes   containing  about  150  figures,  beautifully  colored,  many  of  them  the  ^e  of 
hfe;  strongly  bound  m  cloth,  $17  00  ;  also,  in  five  parts,  stout  wrappers,  at  $3perpart 
Anticipating  a  very  large  sale  for  this  work,  it  is  oflFered  at  the  very  low  price  of  Three  DoL - 
LIRS  aPart,thus  placing  it  within  the  reach  of  all  who  are  interested  in  this  department  of 
Zu^''^\  ^^n^'e'nen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without 
ieiaj .     A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents 


LEE-S  I-ECTURES  ON  SYPHILIS  AND  SOME 
FORMS  OF  LOCAL  DISEASE  AFFECTING  PRIN- 
CIPALLY THE  ORGANS  OF  GENERATION.  In 
one  handsome  octavo  volume;  cloth,  ^-l  2.t. 


Hir.L  ON  SYPHILIS  AND  LOCAL  CONTAGIOUS 
DISORDEKS.  In  one  handsome  octavo  volumt ; 
cloth,  $3  2.>. 


^EST  {CHARLES),  M.D., 

Physician  to  the  Ho^-pital for  Sick  Chi/dren,  London,  &e 

LECTURES  ON  THE  DISEASES  OF  INFANCY  AND 


CHILr- 


HOOD.  Fifth  American  from  the  sixth  revised  and  enlarged  English  edition.     Tnonelar<'e 
and  hanasomeoctavo  volume  of  678  pages.    Cloth,  $4  50  ;  leather,  $5  50.  {LaU/y  Isme,7.) 

gr  THE  SAME  AUTHOR.    (Lately  Issued.)  ' 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 
HOOD; being  the  Lumleian  Lectures  delivered   at  the  Royal  College  of  Physicians  of 
London,  in  March,  1871.     In  one  volume    small  12mo.,  cloth,  $1  00. 
gr  THE  SA  ^E  AUTHOR.  

LECTURES  ON  THE  DISEASES  OF  WOMEN.     Third  American, 

from  the  Third  London  edition.     In  one  neat  octavo  volume  of  about  550  pages,  clotL', 
$3  75;  leather,  $4  75.  r  o     >  i 

T^SFs'^OP^'.mTit-Pv'^^'^:^'^!.^^.'^^  ^"^  ^'^■'  SMITH'S  PRACTICAL  TRE\TISE  ONTHEWASr 
«nd   «n.rnlnVj        r  ,   '^"^    edition,    revised  ,      ING  DISEASES  OF  INFANCY  AND  CHt.DH  )OD. 

^pfvit    <^o     ',:L,i     Jl""?  l"''^*  "'^'''T"  !"'"™*'  «'  1       *^'"=""''  American,   from  the  second   revi.sed  and 


neirly   S'O   closely-printed    pages,  cloth.   £.5  2.5- 
leather,  $5  25.  ■  *         , 


enlarged  Eoelish  edition. 
TO  voiame,  cloth,  $2  00. 


In  one  handsome  octa- 


Henry  C.  Lea's  Son  &  Co.'s  Publications— (Z)is.  of  Children,  &c.).    21 
^MITH  {J.  LE  WIS),  M.D., 

Clinical  Professor  ofDisensps  of  Ohildro.n  in  the  Bellevue  Hnspitnl  Mfd.  College,  N  T. 

A  COxMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF 

CHILDREN.  Fourth  Editioa,  revised  and  enlarged.  In  one  handsome  octavo  volume 
of  about  750  pages,  with  illustrntions.  Cloth,  $4  50  ;  leather,  $5  50.  'uyoiv  Ready.) 
The  very  marked  favor  with  which  this  work  has  been  received  wherever  C.e  English  lan- 
guage is  spoken,  has  stimulated  the  author,  in  the  preparation  of  the  Fourth  Edition,  to  spare 
no  pains  in  the  endeavor  to  render  it  worthy  in  every  respect  of  a  continuance  of  profession.-il 
confidence.  Many  portions  of  the  volume  have  been  rewritten,  and  much  new  matter  intro- 
duced, but  by  an  earnest  effort  at  condensation,  the  size  of  the  work  has  not  been  materi;illy 
increased.  - 


In  the  period  which  has  elapsed  since  the  third 
edition  of  the  work,  so  extensive  have  been  the  ad- 
vances that  whole  chapters  required  to  be  rewritten, 
and  hardly  a  page  could  pass  without  some  material 
correction  or  addition.  This  labor  has  occupied  the 
writer  closely,  and  he  has  performed  it  conscien- 
tiously, so  that  the  book  may  be  considered  a  faith- 
ful portraiture  of  an  exceptionally  wide  clinical 
experience  in  infantile  diseases,  corrected  by  a  care- 
ful study  of  the  recent  literature  of  the  subject. — 
Med.  and  Surg.  Reporter,  April  5,  1879. 

It  is  scarcely  necessary  for  us  to  say  tho  work  be- 
fore us  is  a  standard  work  upon  diseases  of  children, 
and  that  no  work  has  a  higher  standing  than  it  upon 
those  affections.  In  consequence  of  its  thorough  re- 
vision, the  work  has  been  made  of  more  value  than 
ever,  and  may  be  regarded  as  fully  abreast  of  the 
times.  We  cordially  commend  it  to  students  and 
physicians.  There  is  no  better  work  in  the  language 
on  diseases  of  children. — Cincinnati  Med.  News, 
March,  1879. 

The  author  has  evidently  determined  that  it  shall 
notlo.se  ground  in  the  esteem  of  the  profession  for 
want  of  the  latest  knowledge  on  that  important 
department  of  medicine.  He  has  accordingly  in- 
corporated in  the  present  edition  the  useful  and 
practical  reiults  of  the  latest  study  and  experience, 
bHh  American  and  foreign,  especially  those  bearing 
on  therapeutics.  Altogether  the  book  has  been 
greatly  improved,  while  it  has  not  been  greatly 
increased  in  size.  —  iPew  York  Medical  Jotcrnal, 
June,  1S79. 


This  excellent  work  is  so  well  known  that  an 
ex  ended  notice  at  this  time  would  be  superfluous. 
The  author  has  taken  ndvantage  of  the  demand  for 
another  new  edition  to  revise  in  a  most  careful 
manner  the  entire  book  ;  and  the  numerous  correc- 
tions and  additions  evince  a  determination  on  bis 
part  to  keep  fully  abreast  with  the  rajiid  progress 
that  is  being  made  in  the  knowledge  and  treatment 
of  children's  diseases.  By  the  aduptioa  of  a  some- 
what closer  type,  an  increase  in  size  of  only  thirty 
pages  has  been  necessitated  by  the  new  subject 
matter  introduced. — Boston  Med.  and  Surg'.  Jour., 
May  29,  1S79. 

Probably  no  other  work  ever  published  in  this 
country  upon  a  medical  subject  has  reached  such  a 
heighth  of  popularity  as  has  this  well-known  trea- 
tise. As  a  text  and  reference-book  it  is  preemi- 
nently  the  authority  upon  diseases  of  children.  It 
stands  deservedly  higher  in  the  estimation  of  the 
profession  than  any  other  work  upon  (he  same  sub- 
ject.— Nashville  Journ.  of  Med.  and  Surg.,  filay, 
1879. 

The  author  of  this  work  has  acquired  an  immense 
experience  as  physician  to  three  of  the  large  char- 
ities of  New  York  iu  which  children  are  treated. 
These  asylums  afford  unsurpassed  opportunities  for 
observing  tlie  effects  of  different  plans  of  treatment, 
and  the  fesults  as  embodied  in  this  volume  may  be 
accepted  with  faith,  and  should  be  in  the  possessiou 
of  all  practitioners  now,  in  vi^w  of  the  approaching 
season  when  the  diseases  of  children  always  increase. 
—Nat.  Med.  Remtw,  April,  1879. 


gWAYNE  [JOSEPH  GRIFFITHS),  M.D., 

Physioinn-Accotioheurtothe  British  General  ffo.ipital,  d-c. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COM- 
MENCING MIDWIFERY  PRACTICE     Second  American,  from  the  Fifth  and  Revised 
London  Edition,  with  Additions  by  E.  R.  Hutohins,  M.D.  With  Illustrations.   In  one 
neat  12mo.  volume.     Cloth,  $1  25.     {Lately  h.'nied.) 
***  See  p.  4  of  this  Catalogue  for  the  terms  on  which  thi.s  work  is  offered  as  a  premium  to 
subscribers  to  the  "  American  Journal  of  the  Medical  Sciences." 


CHnROHILL  ON  THE  PUERPERAL  FEVER  AND 
OTHER  DISEASES  PECULIAR  TO  WOMEN.  1vol. 
''vo.,  pp.  l.'if),  cloth.     )i!2  oO. 

DEWEES'8  TREATISE  ON  THE  DISEASES  OFFE- 
MALES.  With  illus^rations.  Eleventh  Edition, 
with  the  Author's  lastimprovementsand  correc- 
tions. In  one  octavo  volume  of  536  pages,  with 
plates,  cloth.    *;.^  00. 


."MEIGS  ON  THE  NATURE,  SIGNS,  AND  TREAT- 
MENT OF  CHILDBED  FEVER.    1  vol.  Svo  ,  pp. 

Se.-i.  cloth.     .$'2  00. 

ASHWELL'S  PRACTICALTKEATISEONTHE  DIS- 
EASES PECULIAR  TO  WOMEN.  Third  Americi-n, 
from  the  Third  and  revised  London  edition.  1  vol. 
Svo.,  pp.  528,  cloth.    $3  50. 


JJODOE  (HUGH  L.),  M.D., 

Erneritu.i  Profes.-ior  of  Obstetrics,  &c.,  in  the  University  of  Pennsylvania. 

ON  DISEASES  PECULIAR  TO  WOMEN  ;  including  Di.spl.accmcnls 

of  the  Uterus.     With  original  illu.strations.    Second  edition,  revised  and  enlarged.     In 

one  beautifully  printed  octavo  volume  of  531  pages,  cloth,  $4  50. 

Professor  Hodge's  work  Is  truly  an  original  one  I  contribution  to  the  study  ofworaen'sdlseaseB.itisrf 

from  beginning  to  end,  consequently  no  one  can  pe-    great  value,  and  is  abundantly  able  to  stand  on  its 

ruseits  pageswithout  learningsomething  new.  Ata  |  own  merits.— JV.  Y.  Medical  Record,  Sept.  16,  ISb! . 

HURGHILL  {FLEETWOOD),  M.D.,  M.R.I.A. 
ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.    A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.  With  notes  and  additio-i  s 
by  D.  Francis  Condie,  M.D.,  author  of  a  "  Practical  Treatise  on  the  Diseases  of  Chil- 
dren," Ac.  With  one  hundred  and  ninety  four  illustrations.  In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.     Cloth,  $4  00  ;  leather,  $5  00. 

MONTGOMERY'S  EXPOSITION  OF  THE  SIGNS  ;  RlOBT'b  SYSTEM  OF  MIDWIFERY.  With  notes 
AND  SYMPTOMS  OF  PREGNANCY.  With  two  I  and  Additional  Illustrations.  Second  Amerl.Hu 
exqnlsitecolored  plates,  and  numerous  wood-cuts.  I  «d(tion.  One  volume  octavo,  cloth  422  pages, 
Inl  7ol.8TO.,ofnearly600pp.,olotb,$3  76.  i     $2  50. 


o 


22      Henry  C.  Lea's  Son  &  Co.'s  Publications — {Dis.  of  Women). 
rPHOMAS  [T.GAILLARD),M.D., 

*•  Prnfm.sor  nf  Obitetricf:,  A-c.  in  the  College  of  Physicians  and  Surgeons,  N.  T.,  Ac. 

A  PRACTICAL  TREATISE  OX  THE  DISEASES  OF  WOMEN.  Fourth 

edition,  enlarged  and  thoroughly  revised.  In  one  large  and  handsome  o<;tavo  volume  of 
800  pages,  with  191  illustrations.     Cloth,  $5  00;  leather,  $6  00.     (Just  Issued.) 

The  author  has  taken  advantage  of  the  opportunity  afforded  by  the  call  for  another  edition  of 
this  work  to  render  it  worthy  a  continuance  of  the  very  remarkable  favor  with  which  it  has  been 
received.  Every  portion  has  been  subjected  to  a  conscientious  revision,  and  no  labor  has  been 
spared  to  make  it  a  complete  treatise  on  the  most  advanced  condition  of  its  important  subject. 

A  work  which  has  reached  a  fuurth  edition,  and  is  classical  without  beingpedantic. full  in  I  lie  details 
that.  too.  in  the  short  space  of  five  years,  has  achieved  of  anatomy  and  pathology,  without  ponderous 
a  reputation  which  plai;es  it  almost  beyond  the  reach  translation  of  pages  of  German  literature,  describes 
of  criticism,  and  the  favorable  opinions  which  we  have  distiuclly  the  details  and  difficulties  of  each  opera- 
a'ready  expressed  of  the  former  editions  seem  to  re-!  tion,  without  wearying  and  useless  minutia,  and  is 
quire  that  we  should  do  little  more  than  announce  in  all  respects  a  work  worthy  of  confideuce.justify- 
this  new  issue.  We  cannot  refrain  from  saying  that,  ing  the  high  regard  in  which  its  distingui<hed  an- 
as a  practical  work,  this  is  second  to  none  in  the  Kuk-  thor  is  held  by  the  profession. — Am.  Supplement, 
lish.  or.  indeed,  in  any  other  lan'.;ua}re.    The  arranae-    Ob-S'tet.  Journ.,  Oct.  1S7-1. 

ment  of  the  contents,  the  adniir:ililv  clear  manner  in         „,  „,  ,,  ,,t^,.  ,, 

which  the  subject  of  the  differential  rtia.>-nosis  of :  ProfessorThomasfairly  took  the  Profession  of  the 
severalof  the  diseases  is  handled,  leave  nothi'n.'  to  be  t^ii'ed  States  by  storm  when  his  book  first  made  its 
de.sired  by  the  practitioner  who  wahts  a  thnrouc^hly  '  appearance  early  in  1S6S.  Its  reception  was  simply 
clinical  work,  one  to  which  he  can  re+'er  in  difficult  enthusiastic,  notwithstanding  a  few  adverse  criti- 
cases  of  doubtful  diairnbsis  with  the  certainti' of  gain-  !  C'sm^  f'om  our  transatlantic  brethren,  the  first  large 
in;:  liu'htand  instruction.   Dr.  Thomas  is  a  man  with  a  !  edition  was  rapidly  exhausted,  and  in  six  months  a 


second  one  was  issued,  and  in  two  years  a  third  one 
was  announced  and  published,  and  we  are  now  pro- 
mised the  fourth.  The  popularity  of  this  work  was 
not  ephemeral,  and  itssuccess  was  unprecedented  In 
the  annalsof.^raerican  medical  literature.  Six  years 
is  a  long  period  in  medical  scientific  research,  but 
Thomas's  work  on  "  Diseases  of  Women"  is  still  the 
leading  native  production  of  the  United  States.  The 
order,  the  matter,  the  absence  of  theoretical  dispuia 
tiveness,  the  fairness  ofstatement,  and  the  elegance 
of  diction,  preservf  d  throughout  the  entire  range  of 
the  book,  indicate  that  Professor  Thomas  did  not 
overestimate  his  powers  when  he  conceived  the  idea 
and  executed  the  work  of  producing  a  new  treatise' 
uiion  diseases  of  women. — Prop.  Fallen,  in  Louis- 
This  volume  of  Prof.  Thomas  in  its  revised  form    ville  Med.  Journal,  Sept.  1S74. 


very  clear  head  and  decided  views,  and  there  seems  to 
be  nothin;^  which  he  so  much  dislikes  as  hazy  notions 
of  Uiaanosis  and  blind  routine  and  unreasonable  thera- 
peutics. The  student  who  will  thorouarhly  study  this 
b  lok  and  test  its  principles  by  clinical  observation,  will 
certainly  not  be  guilty  of  these  faults.— iowdon  Lancet, 
Feb.  1.3,  1873 

Reluctantly  we  are  obliged  to  close  this  unsatis- 
factory notice  of  so  excellent  a  work,  and  in  conclu- 
sion would  remark  that,  as  a  teacher  ofgynajcology. 
both  didac'ic  and  clinical,  Prof.  Thorn  as  has  certainly 
taken  the  lead  far  ahead  of  his  cnnfr'erefi,  and  as  ais 
author  he  certainly  has  met  with  unusual  and  mer- 
ited success.— ^571  "./')wr?i.  of  Obstetrics,  Xov.  1874. 


'DARNES  [ROBERT),  M.D.,  F.R.C.P., 

■'-'  Ob-itetric  Phy.sician  to  St.  Thomas".':  Ho.^jjital,  Ac. 

A  CLINICAL  EXPOSITION  OF  THE  MEDICAL  AND  SURGI- 
CAL diseases  OF  WOMEN.  Second  American,  from  the  Second  Enlarged  and  Revised 
English  Edition.     In  one  handsome  octavo  volume,  of  784  pages,  with  181  illustrations. 
Cloth,  $4  50;  leather,  $5  60.      (Just  Ready.) 
The  call  for  a  new  edition  of  Dr.  Barnes's  work  on  the  Diseases  of  Females  has  encouraged 
the  author  to  make  it  even  more  worthy  of  the  favor  of  the  profession  than  before.     By  a  rear- 
rangement and  careful  pruning  space  has  been  found  for  a  new  chapter  on  the  Gynaecological 
Relations  of  the  Bladder  and  Bowel  Disorders,  without  increasing  the  size  of  the  book,  while 
many  new  illustrations  have  been  introduced  where  experience  has  shown  them  to  be  needed.    It 
is  therefore  hoped  that  the  volume  will  be  found  to  reflect  thoroughly  and  accurately  the  present 
condition  of  gynaecological  science. 

Dr   Barnes  stands  at  the  head  of  his  profession  in   the  work  is  a  valuable  one,  and  should  be  largely 
the  old  country,  and  it  requires  but  scant  scrutiny    cin-ulted  by  the  profession.— /Im.  Sf'pp  Obstetrical 
of  his  book  to  show  that  it  has  been  sketched  by  a  ;  Journ.  Gt.  Britain  and  Ireland,  Oct.  1S78. 
master.     It  is  plain,  practical  common  sense;  shows 


No  other  gynajcological  work  holds  a  higher  posi- 
tion, having  become  an  authority  everywhere  in 
diseases  of  women.  The  work  has  been  brought 
fiiMv  abreast  of  present  knowledge.  Every  practi- 
tioner of  medicine  should  have  it  upon  the  shelves 
of  his  library,  and  the  student  will  find  it  a  superior 
text-book. — Cincinnali  Med.  News,  Oct.  1S7S. 

This  second  revised  edition,  of  course,  deserves  all 
the  commendation  given  to  its  predecessor,  with  the 
additional  one  that  it  appears  to  include  all  or  nearly 
all  the  additions  to  our  knoivledge  of  its  subject  that 
able  practice  in  diseases  of  women,  has  no  copy  of,  have  been  made  since  the  appearance  of  the  first  edi- 
"  Barnes"' for  daily  consultation  and  instruction.  It  tion.  'J'he  American  references  are,  for  an  English 
is  at  once  a  book  of  great  learning,  research,  and  work,  especially  full  and  appreciative,  and  we  can 
individual  experience,  and  at  ilie  same  time  emi-  cordially  recommend  the  volume  to  American  read- 
nently  practical.  That  it  has  been  appreciated  by  ers. — Journ.  of  Nervous  and  Mental  Disease,  Oct. 
the   profession,  both   in    Great   Britain    and  in  this    1S7S. 


very  deep  research  without  being  pedantic;  is  emi- 
nently calculated  to  inspire  enthu>iasra  without  in- 
culcating rashness;  points  out  tlie  dangers  to  be 
avoided  as  well  as  the  success  to  be  achieved  in  the 
various  operations  connected  with  this  branch  of 
medicine;  and  will  do  much  to  smooth  the  rugged 
path  of  the  young  gyna:cologist  and  relieve  the  per- 
plexity of  the  man  of  mature  years.  —  Canadian 
Journ.  of  Med.  Science,  Nov.  1878. 

We  pity  the  doctor  who,   having  any   consider- 


country,  is  shown  by  the  second  edition  following 
so   soon  upon   the   first. — Am.   Practitioner,   Nov. 

1878. 

Dr  Barnes's  work  is  one  of  a  practical  character, 
largely  illustrated  from  cases  in  his  own  experience. 


This  second   edition  of  Dr.  Barnes's  great  work 
comes  to  us  containing  many  additions  and  improve- 
ments which   bring  it  up  to  date  in  every  feature. 
The  excellences  of  the  work  are  too  well  known  to 
_     .  .  ,    require  enumention,  and  we  hazard  the  prophecy 

bat  by  no  means  confined  to  such,  as  will  be  learned  that  they  will  for  many  years  maintain  its  high  po- 
from  the  fact  that  he  quotes  from  no  lef-s  than  628  sition  as  a  standard  text-book  and  guide  book  for 
medical  authors  in  numerous  countries.  Coming  students  and  practitioners.  —  N.  C.  Med.  Journ., 
from  such  an  author,  it  is  not  necessary  to  say  that  i  Oct.  1878. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Dis.of  Women).      23 


rpMMET  {THOMAS  ADDIS).  M.D 

-'--'  Stirgeon  to  the.  Womnn\^  Hoxpital,  New  York,  etc. 

THE  PRINCIPLES  AND  PRACTICE  OF  GYNECOLOGY,  for  the 

use  of  Students  and  Practitioners  of  Medicine.     In  one  large  and  very  handsome  octavo 
volume  of  856  pages,  with  130  illustrations.     Cloth,  $5;    leather,  $fi.      (Noiv  Ready.) 


It  may  be  i^aid  that  be  has  had  npportnnities  for 
observat'on  and  experience,  for  unfettered  and  nn- 
restraiued  experimentation,  nnd  for  testing  the 
value  of  the  original  and  dazzling  operations  first 
proposed  and  perfi)rmed  by  his  illustrious  predpces- 
sors  before  referred  to,  and  for  devising  new  opera- 
tions and  di-coveriiig  pathological  causes  never 
before  su^ppctfd  or  described,  which  no  man  in  the 
profession  has  ever  before  secured.  We  also  think 
that  the  re;)der-i  of  this  work  will  agree  with  ns, 
after  its  careful  perusal,  that  he  has  a  rare  capacity 
for  discriminating  analy.-^is,  and  generally  for  phi- 
losoptiica!  deduction  and  the  equally  important 
quality  of  patient,  honest,  cominued  work.  For  the 
work  as  a  whole,  we  have  only  praise.  It  deserves 
and  will  re<eivp  the  careful  study  of  all  who  desire 
to  keep  on  a  level  with  the  progress  of  Gynsecology. 
It  embodies  a  largr  amount  of  carefully  analyzed 
personal  experience  in  a  unique  field  for  observa- 
tion than  any  volume  on  Diseases  of  Women  which 
his  yet  been  published.  Its  grtat  merit  consists  in 
this— coming  as  it  does  from  a  thoroughly  honest, 
competent  and  able  specialist,  who  became  a  spe- 
cialist only  after  au  < xcellent  training  and  experi- 
ence as  a  general  hospital  phy-ician  and  surgeon. 
The  book  is  not  one  to  be  hastily  glanced  over,  but 
willsecuretl  e critical  stu-ly  of  Gynajcologists.   Not 


only  its  style,  which  Is  individual  and  somewhat 
peculiar,  but  th'i  new  facts  which  it  brings  out,  its 
original  sngge-tions,  its  numerous  and  important 
statistical  table~,  *nd.  in  some  instances,  its  unex- 
pected deductions,  w'll  compel  attention,  and  will 
form  the  basis  for  a  great  deal  of  Gy na;cological 
stndyand  literature  in  the  future.  All  who  make 
themselves  familiar  with  the  contents  of  this  vol- 
ume, will  feel  assured  that  T>r  Emmet  has  well 
earned  and  wpU  deserved  the  reputation  which  he 
has  already  won,  as  one  of  tie  great  Gynaecologists 
of  the  present  age — The  Am.  Journ.  of  Obstetrics, 
April,  1S79. 

Wehave  examined  this  book  with  something  more 
than  ordinary  care,  and  now  lay  it  aside  captivated 
by  our  impressions  of  it.  From  first  to  last,  each 
page  grows  in  interest,  and  one  is  struck  -with  the 
practical  tore  of  all  that  is  said.  It  is  indeed  the 
gynacological  work  for  the  practitioner.  Its  equal 
is  not  yet  published,  or  at  least  we  have  not  seen  it. 
We  cannot  send  hi"  notice  forward  without  rei'er- 
aticg  that,  in  o^r  e.'tiraation,  Emmet's  Principles 
a^nd  Practice  of  Gynajcology  is  undoubtedly  thebest 
book  for  the  student,  as  well  as  the  general  practi- 
tioner, which  is  at  present  published. —  Va.  Med. 
Monthly,  May,  1879. 


nUiYCAN  {J.  MATTHEWS),  3I.D.,  LL.D., 
CLINICAL    LECTURES    ON    THE 


F.R.S.E..  etc. 
DISEASES    OF    WOMEX, 

Delivered  in  Saint  Bartholomew's  Hospital.     In  one  very  neat  octavo  volume  of   173 

pages.     Cloth,  S!  50.      {Just  Ready.) 
Prof.  Matthews  Duncan's  originality  and  suggestiveness  are  sufficient  guarantee  that  what- 
ever he  may  see  fit  to  lay  before  the  profesion  is  well  worth  attention  ;   while  the  importance 
of  the  subjects  discussed  in  the  present  volume  will  give  it  special  attractivene.-s  to  the  practising 
physician. 


We  ha^e  read  this  book  with  a  great  deal  of  plea- 
sure. It  is  fiill  of  good  things.  The  hints  on  lath- 
ology  and  treatment  scattered  throuKh  the  book  are 
sound,  trus  worthy,  and  of  great  value.  A  healthy 
gkepticitin,  a  'arge  experience,  and  a  clear  j"dg- 
mout  are  everywhere  manifest.  Ins'ead  of  bristling 
with  advice  of  doubtful  value  and  unsound  charac- 


ter, the  book  is  in   every  lespect  a  safe  guide — The 
London  Lancet ,  .Tan   24,  ISSO. 

The  author  is  a  remarkably  clear  lecturer,  and  his 
discussion  of  syinpioms  and  treatment  is  full  and 
suggesiive.  It  will  beawork  which  will  not  fail  to 
be  rehd  with  benefi  by  oractitioners  as  well  as  by 
students.— P/uu<.  Mtd.  and  Surg.  Reporter,  Feb. 
7,  18S0. 


o 


HAD  WICK  [JAMES  R.),  A.M.,  M.D. 

i  i\LVNUAL  OF  THE  DISEASES  PECULIAR  TO  WOMEN. 

neat  volume,  royal  12mo  ,  with  illustrations.     (Frepariiig.) 


In  one 


L>A MSB 0 THA M  ( ERA NCIS  H.),  M.D. 
THE  PRINCIPLES  AND  PRACTICE 


OF  OBSTETRIC   MEDI 

CINE  AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  Keating,  M.  D., 
Professor  of  Obstetrics,  <tc.,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  Iiree 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  raised 
bands  ;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  containing  in 
all  ir»>arly  200  large  and  beautiful  figures.     $7  00. 


TXTINCKEL  [F.], 

'  '  Vrofessor  and  Director  of  the.  Gynecological  Clinic  in  the  University  of  Ro.s-tock. 

A  COMPLETE  TREATISE  ON  THE  PATHOLOGY  AND  TREAT- 
MENT OF  CHILDBED,  for  Students  and  Practitioners.  Translated,  with  the  consent 
of  the  author,  from  the  Second  German  Edition,  by  James  Rkad  Chadwhk,  M.D.  In 
one  octavo  volume.     Cloth,  $4  00.     (Lately  Issued.) 


T 


TANNER  [THOMAS  H.),  M.D. 
ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.    First  Amerionn 

from  the  Second  and  Enlarged  English  Edition.     With  four  colored  plates  and  illustra- 
tions on  wood.    In  one  handsome  octavo  volume  of  about  500  pages,  oloth,  $4  25. 


24         Henry  C.  Lea's  Son  &  Co.'s  Publications — (31idwifery). 


P 


LAYFAIR  (  W.  5.),  M.D.,  F.R.C.F., 

Proft:f.sor  of  Obstetric  Me.dicine  in  King's  Colle.r/e,  etc.  etc. 

A  TREATISE  ON  THE  SCIENCE  AND  PRACTICE  OF  MIDWIFERY. 

Third  American  edition,  revised  by  the  author.  Edited,  with  additions,  by  Robert  P. 
Harris,  M.D.  In  one  handsome  octavo  volume  of  about  700  pages,  with  nearly  210 
illustrations.     Cloth,  $4  ;  leather,  $5.     {Just  Ready .) 

EXTRACT    FROM    THE    AUTHOR'S    PREFACE. 

The  second  American  edition  of  my  work  on  Midwifery  being  exhausted  before  the  corre- 
sponding English  edition,  I  ciinnot  better  show  my  appreciation  of  the  kind  reception  my  book 
has  received  in  the  United  States  than  by  acceding  to  the  publisher's  request  that  I  should 
myself  undertake  the  issue  of  a  third  edition.  As  little  more  than  a  year  has  elapsed  since 
the  second  edition  was  issued,  there  are  naturally  not  many  changes  to  make,  but  I  have, 
nevertheless,  subjected  the  entire  work  to  careful  revision,  and  introduced  into  it  a  notice  of 
most  of  the  more  important  recent  additions  to  obstetric  science.  To  the  operation  of  gastro- 
elytrotomy — formerly  described  along  with  the  Cajsarean  section — I  have  now  devoted  a  sepa- 
rate chapter.  The  editor  of  the  Second  American  edition.  Dr.  Harris,  enriched  it  with  many 
valuable  notes,  of  which,  it  will  be  observed,  I  have  freely  availed  myself. 

A  few  notices  of  the  previous  edition  are  subjoined. 

The  bast  work  on  the  subject  ever  published  in  the  ]  There  has  been  a  general  unanimity  of  opinion  in 
English  laugiiaiie.  It  is  written  in  a  clear,  pleasant  i  the  profession  as  to  the  high  character  of  Dr.  Play- 
style,  without  that  verbosity  which  characterizes  fair's  work,  both  as  a  manual  for  ilie  student,  and 
some  modern  and  highlyprete'utious  works.  The  au- i  a  book  of  reference  for  the  practitioner  ;  and  the 
thor  is  quite  np  with  the  times,  both  in  practice  and  i  revision  and  additions  made  to  ihe  second  edition 
theory.  It  is  the  best  text-book  ive  liave  for  students,  i  will  not  lower  this  favorable  estimate  of  it.  The 
and  sufficiently  full  of  detail  to  supply  all  the  wants  I  additions  made  by  Dr.  Harris  are  of  such  a  char- 
of  the  practitioner.  We  would  gladly  see  it  in  the  acter  as  to  make  us  wish  they  were  more  in  nnm- 
hauds  of  all  who  practise  midwifery.  —  Canadian  ber  and  greater  in  extent. —  Am.  Journ.  of  Med. 
Journ.  of  Med.  Sci.,  Nov.  1S7S.  I  Sciences,  Jan.  1S79. 

jyARiVES  [FANCOURT),  31. D., 

-'--'  Physician  to  the  General  Lying-in  Hospital,  London. 

A  MANUAL  OF  MIDWIFERY  FOR  MID WI YES  AND  MEDICAL 

STUDENTS.  With  50  illustrations.  In  one  neat  royal  12mo.  volume  of  200  pages; 
cloth,  $1   25.     {Now  Ready.) 


The  book  is  written  in  plain,  and  as  far  a»  pos- 
sible in  untechnical  language.  Any  intelligent  mid- 
wife or  medical  btuient  can  easily  comprehend  the 
directions  It  will  undoubtedly  till  a  want,  fnd 
will  be  popular  with  those  for  whom  it  has  been 
prepared.  The  examining  questions  at  the  back 
will  be  found  very  useful. — Cincinnati  Med.  News, 
Aug.  1879. 


The  style  Is  clear,  and  the  book  will,  doubtless, 
be  useful  to  the  persons  for  whom  it  is  intended. — 
London  Med.  Times  and  Gazette,  Aug.  30,  1S79. 

The  book  is  written  with  as  little  technical  lan- 
guage as  possible.  Any  intelligent  midwife  or  med- 
ical student  can  easily  understand  the  directions. 
It  will  undoubtedly  be  found  very  useful. — Otiio 
Med.  Recorder,  Sept.  1S79. 


rpHE  OBSTETRICAL  JO  URNAL.     {Free  of  postage/or -i8S0.) 

'THE  OBSTETRICAL  JOURNAL  of  Great  Britain  and  Ireland; 

Including   Midwifery,  and  the  Diseases  op  Women  and  Infants.     A  monthly  of 
64  octavo  pages,  very  handsomely  printed.     Subscription,  Three  Dollars  per    annum 
Single  Numbers.  25  cents  each. 
With  the  J;inuary  number  will  terminate  Vol.  VII.  of  the  Obstetrical  Journal.     The  first 
No.  of  Vol.  VIII.  will  be   issued  about  Feb.  1st;  the  "American  Sdpplement"  of  16  pages 
per  No.  will  be  discontinued,  and  the  periodical  will  thenceforth  consist  of  64  pages  per  number, 
at  the  exceedingly  low  price  of  Three  Dollars  per  annum,  free  of  postage.     For  this  trilling 
f  um  the*  subscriber  will  thus  obtain  more  than  760  pages  per  annum,  containing  an  extent  and 
variety  of  information  which  may  be  estimated  from  the  fact  that  Vol.  VI.  of  the  "  Obstetri- 
cal Journal"  contains  in 


Original  Communications     .     .  44  Articles 
Hospital  Phactice      ....        4      " 
General  Correspondence    .     .        5      " 

Reviews  of  Books 9      " 

Pkockedings  of  Societies    .     .  101       " 


In  Monthly  Summary,  Qynkcic 

"                 "             Pediatric 
News 


28  Articles 
4 
9       " 

241 


In  Monthly  Summary,  Obstetric  73  " 
and  that  it  numbers  among  its  contributors  the  distinguished  names  of  L')mbe  Attiiill,  J.  H. 
AvELiNG,  Robert  Barnes,  J.  Heniiy  Bennet,  Nathas  Bozf.man,  Thomas  Chambers,  Fleet- 
wood Churchill,  Charles  Clav,  John  Clay,  J.  Matthews  Duncan,  Arthur  Farre,  Robkrt 
Greenhalgh,  W.  M.  Graily  Hewitt,  J.  Braxton  Hicks,  William  Leishman,  Angus  Mac- 
DONALD,  Alfred  Meadows,  Alex.  Simpson,  J.  G.  Swayne,  Lawson  Tait,  Edward  J.  Tilt, 
E.  H.  TitKXHOLME,  T.  Spencer  Wells,  Arthur  Wigglesworth,  and  many  other  distin- 
guished practitioners.  Under  such  suspices  it  has  amply  fulfilled  its  object  of  presenting  to 
the  physician  all  that  is  new  and  interesting  in  the  rapid  development  of  obstetrical  and  gynae- 
cological science. 

As  a  very  large  increase  in  the  subscription  list  is  anticipated  under  this  reduction  in  price, 
gentlemen  who  jiropose  to  subscribe,  and  subscribers  intending  to  renew  their  subseriptions, 
are  recommended  to  lose  no  time  in  making  their  remittances,  as  the  limited  number  printed 
may  at  any  time  be  exhausted. 

This  is  certainly  a  very  excellent  journal.  Ilgives  We  cannot  withhold  the  express'on  of  the  admi- 
ns the  best  obstetrical  literature  from  across  the  ration  this  elegant  journal  excites. —  Western  Lanctt, 
water.— //id.  Journ.  of  Med.,  Nov.  1S71.  .March,  1875. 


Henry  C.  Lea's  Son  &  Co.'s, Publications — (3Iidwifery,  Surgery).    25 


^ EISHMAN  [WILLIAM),  M.D., 

Regius  Professor  of  Midwifery  in  the  University  of  Glasgow,  &c. 

A  SYSTEM  OF  MIDWIFERY,  INCLUDING  THE  DISEASES  OF 

PREGNANCY  AND  THE  PUERPERAL  STATE.  Third  American  edition,  revised  by 
the  Author,  with  additions  by  John  S.  Paurv,  M.D.,  Obstetrician  to  the  Philadelphia 
Hospital,  &c.  In  one  large  and  very  handsome  octavo  volume,  of  733  pages,  with  over 
two  hundred  illustrations.     Cloth,  $4  50;  leather,  $5  50.      [Just  Ready.) 


Few  works  on  this  subject  have  met  with  as  great 
a  demand  as  this  one  appears  to  have.  To  judge 
by  the  frequency  with  which  its  author's  views  are 
quoted,  and  its  statements  referred  to  in  obstetrical 
literature,  one  would  judge  that  there  are  few  phy- 
sicians devoting  much  attention  to  obstetrics  who 
are  without  it.  The  author  is  evidently  a  man  of 
ripe  experience  and  conservative  views,  and  in  no 
branch  of  medicine  are  these  more  valuable  than  in 
this. — Kew  Remedies,  Jan.  18S0. 

We  are  glad  to  call  the  attention  of  our  readers  to 
this  new  edition  of  Dr.  Leishnian's  well-known 
work,  which  has  already  established  itself  in  gene- 
ral favor  both  in  this  country  and  in  America.  In 
noticing  this  third  edition,  we  need  only  direct  at- 
tention to  the  ditferences  between  it  and  its  prede- 
cessors. Although  carefully  revised  throughout, 
with  not  a  few  additions  11  various  places,  the  net 
enlargement  amounts  only  to  a  few  pages.—  Glasgow 
Mvdical  Journal,  Ja.n.  ISSO. 


We  gladly  welcome  the  new  edition  of  this  excel- 
lent text-book  of  midwifery.  The  former  editions 
have  been  most  favorably  received  by  the  profes- 
sion on  both  sides  of  the  Atlantic  In  the  prepara- 
tion of  the  present  edition  the  author  has  made  such 
alterations  as  the  progress  of  obstetric  il  science 
seems  to  require,  and  we  cannot  but  admire  the 
ability  with  which  the  task  has  been  performed. 
We  consider  it  an  admirable  text-book  for  stu.leiits 
during  their  attendance  upon  lectures,  and  have 
great  pleasure  in  recommending  it.  As  an  exponent 
of  the  midwifery  of  the  preseot  day  it  has  uo  supe- 
rior in  the  English  language. — Canada  Lancet ,  Jan. 
ISSO. 

The  book  is  greatly  improved,  and  as  snch  will  be 
welcomed  by  those  who  are  trying  to  keep  posted  in 
the  rapid  advances  which  are  being  made  in  the 
study  of  obstetrics. — Boston  Med.  and  iturg  Journ., 
Nov.  i7,  1879. 


F 


ARRY  (JOHN  S.),  M.D., 

Obstetrician  to  the  Philadelphia  Hospital,  Vice-Prest.  of  the  Obstet.  S  ''ciety  of  Philadelphia. 

EXTRA-UTERINE    PREGNANCY:    ITS  CLINICAL  HISTORY, 

DIAGNOSIS,    PROGNOSIS,  AND    TREATMENT.     In  one  handsome  octavo  volume. 
Cloth,  $2  60.     (Lately  Iss^ied.) 


TpBGE  [HUGH  L.),  M.D., 

Emeritus  Professor  of  Midwifery,  &o.,  in  the  University  of  Pennsylvania,  &c. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.     Illns- 

trated  with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.    In  one  large  and  beautifully  printed 
quarto  volume  of  550  double-columned  pages,  strongly  bound  in  cloth,  $14. 
The  work  of  Dr.  Hodge  is  something   more  than  i  fact   or  principle   la  left  unstated  or  unexplained. 


a  simple  presentation  of  his  particular  views  in  the 
dejanment   of   Obstetrics;    it  is   something  more 


Am.  Med.  Times,  Sept.  8,  1864. 

,^  ■  ..  ,       ..  •,„-f         •.  •     -■     r     .   ]      It  18  very  large,  profusely  and  elegantly  illustiat- 

than  an  ,rdinarytr.eatise  on  midwifery;  it  is  in  fact,  j  ^^    ^^^  j^  21,^^  ,^  t^ke  its  place  near  the  works  uf 
a  cyclopaedia  01  rn.dwilery.     He  has  aimed  to  em-    ^^^^^  obstetricians      Of  the  American  works  on  the 


body  in  a  lingle  volume  the  whole  science  and  art  of 
Obstetrics,  in  elaborate  text  is  combined  with  ac- 
curate and  varied  pictorial  illustrations,  so  that  no 


iubjeci  it  is  decidedly  the  best.' 
Dec.  1864. 


-Edinb.  Med.  Jour., 


jlf*)!f  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address,  free  by  mail, 
on  receipt  of  six  cents  in  postage  stamps. 

O T1M80N  ( L E  WIS  A.),  A.M.,  M.D., 

'^  Surgeon  to  the  Presbyterian  Hospital. 

A  MANUAL  OF  OPERATIVE  SURGERY.     In  one  very  iiandsome 

royal  12mo.  volume  of  about  500pages,  with  332  illustrations  ;  cloth,  $2  50.  {Now  Ready  ) 
The  work  before  us  is  a  well  printed,  profusely    performing  them.     The  work  is  handsomely  illus- 


illustrated  manual  of  over  four  hundred  and  seventy 
pages.  The  novice,  by  a  perusal  of  the  work,  will 
gain  a  good  idea  of  the  general  domain  of  operative 


trated,  a u d  the  dot  criptions  are  cle-tr  and  well  drawn. 
It  is  a  clever  and  useful  volume;  every  student 
should  possoFS  one.     The  preparation  of  this  woik 


surgery,  while  the  practical  surgeon  has  presented  i  does  away  with   the    necessity   of    po"dt'riug  ovtr 


to  him  within  a  very  concise  and  intelligible  form 
the  latest  aud  most  approved  selections  of  operative 
procedure.  The  precision  atd  conciseness  with  which 
the  ditl'erent  operations  are  described  enable  the 
author  to  compress  an  immense  amount  of  practical 
informati<T>'  iu  a  very  small  compass. — N.  Y.  Medical 
Record,  Aug.  3,  1878. 

This  volume  is  devoted  entirely  to  operative  sur- 
gery, and  is  intended  to  familiarize  the  student  with 
the  details  of  opt^ratious  and  the  different  modes  of 


SKET'S   OPERATIVE  SURGERY.     In  1  vol.  8to. 
cl.,  of6fl0  pages  ;  wlthabont  lOOwood-cnts.  $3  26 


larger  works  on  surgery  for  de-icriplions  of  opcia- 
tions,  asit  presents  iu  a  nutshell  just  what  is  wanted 
by  the  surgeon  without  an  elaborate  search  to  Hud 
it. — Md.  Mtd  Journal,  Aug.  1878. 

The  author's  conciseness  and  the  repleteneSs  of 
the  work  %vith  valual)le  illustrations  entitle  il  to  lie 
classed  with  the  text-books  for  students  of  operative 
surgery,  and  as  one  of  reference  to  the  prjictiliouer. 
—  Cincinnati  Lancet  and  Clinic,  July  27,  IS'ii-. 


COOPER'S  LECTURES  ON  THE  PRINCIPLES  AND 
Practice  OF  SnROEKY.  Inl  vol.  Svo.cl'h,  7oOp.  !|(2. 

GIBSON'S  INSTITUTES  AND  PRACTICE  OF  8DR- 
OERT.  Eighth  edit'n,  improved  and  altered.  With 
thirty-four  plates.  In  two  handsome  octavo  vol- 
umes, about  1000  pp., leather,  raised  bandf .  $fi  50. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY. 
By  Wii.i.iAM  PiRRiE.F.R  S  E.,  Profoh'r  of  Surgery 
In  the  University  of  Abeideen.    Edited  by  John 


Nbii.l,  M.  D.,  Professor  of  Surgery  in  (he  Pen  11  a. 
MedicalCollege,Surg'n  to  t  he  Pennsylvania  Hos- 
pital,&c.  In  one  very  handsome  octavo  vol.  of 
780  pages,  with  310  illustrations,  cloth,  $H  IC). 

.MILLKIt'-SIMtlNCIPLKSOK  SUKOKKY.  KourtliAnie- 
ric:in,  from  the  Third  Kdiiiburgh  Kditioii.  In  01. e 
lar^ie  Hvo.  vol.  of  700  pages,  with  340  illustrutious, 
cloth,  ^.i'tb. 

MILLKK'S  PRACTICE  OFSURGERY.  Fourth  Amo- 
rican,  from  the  last  Edinburjih  Kdition.  Kuvi.-cd  by 
the  American  editor.  In  one  large  Svo.  vol.ol  neuriy 
7U0  pages,  with  3U4  illustralious:  cloth,  $3  76. 


26 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery), 


pROSS  (SAMUEL  D.),  M.D., 

^-^  Professor  of  Surgery  in  the.  Jefferson  Medical  College  of  Philadelphia. 

SYSTEM  OF    SURGERY:   Pathological,  Diagnostic,  Thornpeutic, 

and  Operative.    Illustrated  by  upwards  of  Fourteen  Hundred  Engravings.   Fifth  edition 
carefully  revised,  and  improved.  In  two  large  and  beautifully  printed  imperial  octavo  vol- 
umes of  about  2300  pp.,  strongly  bound  in  leather,  with  raised  bands,  $16.    {Just  Issved.) 
The  continued  favor,  shown  by  the  exhaustion  of  successive  largeeditions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students.     In 
the  present  revision  no  pains  have  been  spared  by  the  author  to  bring  it  in  every  respect  fully 
up  to  the  day.     To  effect  this  a  large  part  of  the  work  has  been  rewritten,  and  the  whole  en- 
arged  bj  aearly  one-fourth,  notwithstanding  which  the  price  has  been  kept  at  its  former  very 
moderate  rate.     By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  of 
matter  is  condensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary 
octavos.    This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  bind- 
ing renders,  it  one  of  the  cheapest  works  accessible  to  the  profession.     Every  subject  properly 
belonging  to  the  iomain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this 
work  may  be  said  to  have  in  it  a  surgical  library. 


We  have  now  brought  our  task  to  aconclu.-iioii,  and 
have  seldom  read  a  work  wiih  the  practical  viilue  ot 
which  we  have  Ijcen  more  impressed.  Every  chapter  is 
so  concisely  put  together,  tliat  the  busy  practiliimcr, 
when  in  difficulty,  can  at  once  find  the  information  he 
requires;  His  work,  on  the  contrary,  is  cosmopolitiUi. 
tlie  surgery  of  the  world  being  fully  represented  in  it. 
The  work,  iu  fact,  is  so-historically  unprejudiced,  and 
go  euiinentlypractical.that  it  is  almost  a  false  compli 
nient  to  say  that  we  believe  it  to  be  destined  to  occupy 
a  foremost  place  as  a  work  of  reference,  while  a  system 
of  surjery  like  the  present  system  of  surgery  is  the 
practice  of  .-lurgeons.  The  printing  and  binding  of  the 
work  is  unexceptionable;  indeed.it  contrasts,  in  the 
latter  respect,  remarkably  with  Enirlish  medical  and 
surgical  cloth-bound  publications,  which  are  generally 
so  wretchedly  stitched  as  to  require  re-binding  before 
they  are  any  time  in  use. — Vub.  Journ.  of  Med.  &'ci.. 
March,  1874. 

Dr.  Gross's  Surgery,  a  great  work,  has  become  still 
greater,  both  in  size  and  merit,  iu  its  most  recent  forui. 
The  difference  in  actual  number  of  pages  is  not  more 
than  130,  but.  the  size  ot  the  page  having  been  in- 
creased to  what  we  believe  is  technically  termed  ••ele- 
phant," there  has  been  room  for  considerable  :idditions, 
which,  together  with  the  alterations,  are  improve- 
ments.— Lnnrl.  La?ic«;<,  Nov.  16.1872. 

It  comVnnes.  as  perfectly  as  possible,  the  qualities  of 
a  text-book  and  work  of  reference.  We  think  this  last 


ulition  of  Gros-'s  "Surgery,"  will  confirm  his  title  of 
••  PrimusintRT  Fares."  It  is  learned,  scholar-like,  me- 
thodical, precise,  and  exhaustive.  We  scarcely  think 
any  living  man  could  write  socompleteand  faultless  a 
treatise,  or  comprehend  more  solid,  instructive  matter 
in  the  given  number  of  pages.  The  labor  must  have 
been  immense,  and  the  work  gives  evidence  of  great 
powers  of  mind,  and  the  highest  order  of  intellectual 
discipline  and  methodical  disposition,  and  arrangement 
of  acquired  knowledge  and  personal  experience. — N.Y. 
Med.  Journ..  Feb.  1S73. 

As  a  whole,  we  regard  the  work  as  the  representative 
"System  of  Surgery"  in  the  English  language. — St. 
Louis  Mi.dical  and  Surg.  Journ.,  Oct.  1872, 

The  two  magnificent  volumes  before  us  afford  a  very 
complete  vi(nv  of  the  surgical  knowledge  of  the  day. 
Some  years  ago  we  had  the  pleasure  of  presenting  the 
first  edition  of  Gross's  Surgery  to  the  profession  as  a 
work  of  unrivalled  excellence;  and  now  we  have  the 
result  of  years  of  experience,  labor, and  study,  all  con- 
densed upon  the  great  work  before  us.  And  to  students 
or  practitioners  desirousof  enriching  theirlibrary  with 
a  treasure  of  reference,  we  can  simply  commend  the 
purchase  of  these  two  volumes  of  iinmenseresearch  — 
Cincinnati  Lance.tand  Obsercer,  Sept.  l!^72. 

A  completesystem  of  surgery — not  a  mere  text-book 
of  operations,  but  ascientific  accountuf  surgical  theory 
and  practice  in  all  its  departments.— iVti.  and  For. 
Med  Chir.  Rev.,  Jan.  1873, 


B 


T  THE  SAME  AUTHOH. 

A    PRACTICAL  TREATISE   ON  THE  DISEASES,  INJURIES, 

and  Malformations  of  the  Urinary  Bladder,  the  Prostate  Gland,  and  the  Urethra.  Third 
Edition,  thoroughly  Revised  and  Condensed,  by  Samuel  W.  Gross,  M.D.,  Surgeon  to 
the  Philadelphia  Hospital.   In  one  handsome  octavo  volume  of  674  pages,  with  170  illus- 
trations: cloth,  $4  60.     {Just  Issued.) 
For  reference  and  general  information,  the  physician  leases  of  the  urinary  organs. — Atlanta  Med.  Journ., Oct 


or  surgeon  can  find  no  work  that  meets  their  necessiliet 
more  thoroughly  than  this,  a  revi>ed  edition  of  an  ex- 
cellent treatise,  and  no  medical  library  should  be  with- 
out it.  Replete  with  handsome  illustrali  ns  and  good 
ideas,  it  has  the  unusual  advantage  of  being  easily 
comprehended, by  the  rea-onableand  practicnl  manner 
in  which  the  various  subjects  are  sy.-~tematized  and 
arrantred  We  heartily  recommend  it  to  the  profession 
a^i  a  valuable  addition  to  the  important  literature  ofdis- 


1876. 

It  is  with  pleasure  we  now  again  take  up  this  old 
work  in  a  decidedly  new  dress.  Indeed,  it  must  be  re- 
garded as  a  new  book  in  very  many  of  its  parts.  The 
chapters  on  •'  Diseases  of  the  liladder,"  ■•  Prostate 
Body,"  and  "Lithotomy,"  are  splendid  specimens  of 
descriptive  writing;  while  the  cha|)ter  on  '-Stricture" 
is  one  of  the  most  concise  and  clear  that  we  have  ever 
read. — New  i'ork  Med.  Journ.,  Nov.  1876. 


Tjr  THE  SAME  AUTHOR. 

A   PRACTICAL   TREATISE    ON   FOREIGN   BODIES    IN 

AIR-PASSAGES.     In   1  vol.  8vo.,  with  illustrations,  pp.  468,  cloth,  $2  75, 


THE 


riRUITT  [ROBERT],  M.R.C.S.,ifc 
THE  PRINCIPLES  AND  PRA( 


ACTICE  OF  MODERN  SURGERY. 

A  newand  revised  American,  from  the  eighth  enlarged  and  improved  London  edition.  Illus- 
trated with  four  hundred  and  thirty -two  wood  engravings.  In  one  very  handsome  octavo 
volume,  of  nearly  700  large  and  closely  printed  pages,  cloth,  $4  00  ;  leather,  $5  00. 


All  that  the  surgical  student  or  practitioaercould 
desire. — Dublin  Quarterly  Journal. 

It  is  a  most  admirable  book.  We  do  not  know 
IT  hen  we  have  examined  one  with  more  pleasure. — 
Boston  Med.  and  Surg.  Joxirnal. 

In  Mr.Druitt'8  book,thon.gh  containingonly  some 
seven  hundred  pages,  both  the  principles  and  the 


practice  of  surgery  are  treated,  and  so  clearly  and 
perspicuously,  as  to  elucidatee  very  import-in  (topic. 
We  iiave  examioed  thebook  most  thoroughly,  and 
can  jay  that  this  success  is  well  merited.  Hii-book 
moreover,  possesses  the  inestimable  advantages  of 
having  the  subjects  perfectly  well  arranged  acd 
clafsified  and  of  being  written  in  a  style  at  once 
clear  ind  succinct. — Am.  Journal  of  Med.  Sciencee. 


27 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery). 
A  SHHURST  {JOHN,  Jr.),  M.D., 

-^-^  Prcif.  of  Clinical  Siirgn-i/.  Vniv  of  Pa..  Surgeon  to  the  Episcopal  Hospital,  Philadelphia 

THE   PRINCIPLES  AND  PRACTICE  OF  SURGERY.     StcoiKl 

edition,  enlarged  and  revised.     In  one  ^ery  large  and  handsome  octavo  volume  of  over 

1000  pages,  with  542  illustrations.     Cloth,  $6;  leather,  §7.      (Just  Ready.) 

Conscientiousness  and  thorouglinefcs  are  two  very  I      A.shbuv,t'8   Surgery   is   too   well    known    in    this 

marked   trails   of  character  in    the   author  of   this     country  to  rpquire  special   commendation  fnim  us 

book.     Oiit   of  these  trails  largely  lias   grown    the     This,  its  second    edition,  enlnrged   and    thoroughly 

revised,  brings  it  nearer  oiir  idea  of  a  model  Text- 
bo'k  than  any  recently  published  treatise.  Though 
numerous  addi'ions  have  been  made,  tho  size  nf  the 


success  of  his  mental  fruit  in  the  past,  and  the  pre- 
sent offer  seems  in  no  wise  an  exception  to  what  has 
gone  be-fore.  The  general  arrangement  of  the  vol- 
ume is  the  same  as  in  the  first  e.li;iou,  but  I'verypart  j  work  is  not  materially  increased     Tlie  iiiaiutro'ubie 


has  been  carefully  revi.-ed.  and  much    new  matter 
added.— /'/a/a.  Med.  Ti.ues,  Feb.  1,  1S79. 

We  have  previously  spoken  of  Dr.  Ashhurst's 
work  in  terms  .if  praise.  We  wish  to  reiterate  those 
terms  here,  and  to  add  that  no  more  satisfactory 
representation  of  modern  surgery  iias  yet  fallen 
from  the   pr>'ss.     In   point   of  judicial  fairness,  of 


of  text  books  of  modern  times  is  ih:il  (hey  are 
cnraliersome.  The  stndeni  needs  a  hook  which  will 
furnish  him  the  most  information  iu  Ihe  shortest 
time  In  every  respect  this  work  of  Ashhurst  is 
the  model  text  book-  full,  cumprehen.-ive  and  coni- 
pact.— iVv/.s7nv7/e  Jour,  of  Med.  fnid  Surg.,  Jan.  '79. 
The  favorable  r.ceplion  of  the  fir-t  edition  is  a 
power  of  Cimdeusaiioii,  of  accuracy  and  conciseness  j  goarantee  of  the  populariiy  of  th  s  tdilicm,  which  is 


of  expression  and  thoroughly  good  Knglish,  Prof. 
Ashhurst  ha.-s  no  superior  among  ilie  surgical  writers 
in  America. — Am.  Practitioner,  Jan.  1S79. 

The  attempt  to  embrace  in  a  volume  of  1000  pages 
the  whole  field  of  surgery,  general  and  special, 
would  be  a  hopele>s  ta,  k  unless  through  the  most 
tireless  industry  in  collating  and  arranging,  and 
the  wisest  judgment  in  condensing  and  excluding. 
These  facilities  have  been  abundantly  employed  by 
the  author,  and  he  has  given  us  a  most  excellent 
treatise,  brought  up  by  the  revision  for  the  second 
oditioa  to  the  latest  d-tte.  Of  course  this  book  is  not 
designed  for  specialists,  but  as  a  c.iurse  of  general 
surgical  knowledge  and  for  general  praciitioners, 
and  as  a  text-booli  for  students  it  is  not  surpassed 
by  any  that  has  yet  appeared,  whether  of  home  or 
foreign  authorship. — N.  Carolina  Med.  Journal, 
Jan.  )S79. 


I  fresh  from  the  editor's  hands  with  many  enltrge- 
ments  and  improvemen's.  The  author  of  tliis  work 
is  deservedly  popular  as  an  editor  and  writer,  and 
his  contributions  to  the  literature  of  snrgerv  have 
gained  for  him  wide  reputation.  The  volume  now 
offered  the  profe.-sion  will  add  new  Inurels  to  those 
alrendy  won  by  previous  contributions.  We  can 
only  add  that  the  work  i.s  well  arrang  d,  fiUcd  with 
practical  matter,  and  contains  in  brief  and  clear 
languau'e  all  that  is  necessary  to  be  learnej  by  the 
student  of  surgery  whilst  in"  a'tenda  iir,^  npon  lec- 
tures, or  the  general  practitioner  in  his  daily  routine 
practice. — M'l.  Med   -/ournal,  Jan    1S79. 

The  fact  Ih  it  this  work  has  reached  a  second  edi- 
tion so  very  soon  after  the  publication  of  the  first 
one,  speaks  more  highly  of  its  merits  than  auyihiug 
wo  might  say  in  the  way  of  commendation.  It 
seems  to  have  immediately  gained  the  favor  of  stu- 
dents and  physicians. — Cinein.  Med.  Ntws,  Jan.  '79. 


JDRYANT  [THOMAS],  F.R.C.S., 

'^-'  Surgeon  to  Guy's  Hospital. 

THE  PRACTICE  OF  SURGERY.     Socond  American,  from  the  Sec- 

ond  .nnd  Revi.=ed  English  Edition.     With  Six  Hundred  and  Seventy  two  Engravings  on 
Wood.     In  one  large  and  very  handsome  imperial  octavo  volume  of  over  1000  large  and 
closely  printed  pages.     Cloth,  $6;   leather,  $7.      lJu.st  Ready.) 
This  work  hns  enjoyed  the  advantage  of  two  thorough  revisions  at  the  hand  of  the  author  since 
the  appearance  of  the  first  American  edition,  re.sulting  in  a  very  notable  enlargement  of  size  and 
improvement  of  matter.     In  England  this  has  led  to  the  division  of  the  work  into  two  volume.* 
which  are  here  comprised  in  one,  the  size  being  increased  to  a  large  imperial  octavo,  i)rinted  on 
a  conden,?ed  but  clear  type      The  series  of  illustrations  has  undergone  a  like  revision    and  will 
be  found  oorrespondingly  improved. 

The  marked  success  of  the  work  on  both  sides  of  the  Atlantic  shows  that  the  author  has  suc- 
ceeded in  the  effort  to  give  to  student  and  practitioner  a  sound  and  trustworthy  guide  in  the 
practice  of  .Surgery;  while  the  simultaneous  appearance  of  the  present  edition  in  Enu-land  and 
in  this  country  aflbrds  to  the  American  reader  the  benelit  of  the  most  recent  advances  made 
abroad  in  surgical  science. 

Another  edition  of  this  manual  having  been  called 
for,  the  author  has  a va,iieci  him.-elf  of  the upportuuity 
to  make  no  few  alterations  iu  the  sub.^tauce  as  woil 
as  in  llie  arrangement  of  the  work,  and,  with  a  view 
to  its  improvement,  has  ncaM  the  maiorialsaad  re- 
vised tho  whole.     We  ourselves  are  of  the  opinion 

that  there    is  uo   better  work  on  surgery  extant 

Vihclun-Ui  Med.  News,  Blaich,  KS79 

Bryant's  Surgery  has  been  favorably  received  from 
the  ;lr.-l,  and  evideudy  grows  iu  tho  esteem  of  the 
protessiou  «•  th  each  succeeding  edition.  Iu  glanc- 
ing over  the  volume  before  us  we  Hud  proof  in  aimo-t 
every  chapter  of  the  thorough  rev.sion  which  ilie 
work  has  undergone,  maiy  parts  having  bern  cut 
out  and  replaced  by  mitier  entirely  fresh  —A'  Y 
J/«<.  .'oM;•?^.,  April,  1,S79.  ' 

Welcome  as  the  new  edition  is,  and  as  much  as  It 
Ih  entitled  to  commendation,  yet  its  appearance  at 
this  time  is,  lu  a  cer  am  sen^e,  a  matter  ol  regret  as 
it  will  he  111  competiiiin  with  an.dher  woik  lately 
issued  from  the  sane  press,  liut,  the  dilllcull  ta«k 
f  forming  a  Judgment  as  to  the  relative  m-rits  of 


There  are  .so  many  text-books  of  surgery,  so  many 
written  by  skilled  and  ilistinfruished  hands,  that  to  ob 
tain  the  honor  of  a  third  edition  in  England  is  no  l);;ht 
praise.  Mr.  Bryant  merits  this,  by  cliariiesH  of  style, 
and  good  judgment  in  selecting  tlie  operations  he  re- 
commends, in  his  new  editions  lie  goe.o  cnrefully  over 
tho  old  grounds,  in  light  of  later  researili.  Un  these 
and  many  allied  points,  Mr.  Bryant  is  a  calm  and  un- 
partisnn  observer,  and  his  XxtoV.  throughout  lias  the 
great  merit  of  maintaining  the  true  scientific,  judicial 
tone  of  wind. — Med.  and  Surg.  Keforter,  March  22, 
1S70. 

The  work  before  us  is  the  American  reprint  of  the 
last  Londfin  edition,  and  has  the  advantage  over  the 
latter  in  beini:  of  more  convenient  size,  and  in  being 
tx)mpressed  into  one  volume.  'Ihe  author  has  rewrit- 
ten the  greater  part  of  the  work,  ai.d  liiis  sucoeedtd. 
in  the  amount  of  new  matter  added,  in  making  it  mark- 
edly distinctive  from  previous  edi  ions.  A  few  e.xtra 
pages  hav(^  been  added,  and  also  a  lew  new  illustrations 
introduced.  The  putilishers  have  presented  the  work 
in  a  creditable  style.  As  a  conci.se  and  practical  niMnual 
3f  Briti.sh  surgery  it  is  perhaps  without  an  equal,  and 
will  doubtless  always  be  a  favorite  text-book  with  the 
student  and  practitioner. — N.  }\  Med.  liecnrd,  March 
22, 1879, 


liryaui  and  Ashhurst  we  will   not  attempt,  hut  pre- 
dict that,  cou.-iidering  Ihe  high  excellence  of  both 
raanyothers  will  likewise  be  lorced  to  hesitate  Iodk 
in  making  choice  between  ihem  —Ciacinnali  Lan- 
cet and  Clinic,  March  22,  1S79. 


28 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery). 


fiJEICHSEN  {JOHN  E.), 

Proff.ssor  of  Surgery  in  University  College,  London,  etc. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Sur- 
gical Injuries,  Diseases,  and  Operations.  Carefully  revised  by  the  author  from  the 
Seventh  and  enlarged  English  Edition.  Illustrated  by  eight  hundred  and  sixty  two  en- 
gravings on  wood.  Id  two  large  and  beautiful  octavo  volumes  of  nearly  2000  pages  : 
cloth,  $8  50  ;  leather,  $10  50.     (Now  Ready.) 

In  revising  this  standard  work  the  nuthorhas  spared  no  pains  to  render  it  worthy  of  a  continu- 
ance of  the  very  marked  favor  which  it  hns  so  long  enjoyed,  by  bringing  it  thoroughly  on  a 
level  with  the  advance  in  the  science  and  art  of  surgery  made  since  the  nppearnnce  of  the 
last  edition.  To  accomplish  this  has  required  the  addition  of  about  two  hundred  pages  of  text, 
while  the  illustrations  have  undergone  a  marked  improvement.  A  hundred  and  fifty  additional 
wood-cuts  have  been  inserted,  while  about  fifty  other  new  ones  have  been  substituted  for  figures 
which  were  not  deemed  satisfactory.  In  its  enlarged  and  improved  form  it  is  therefore  pre- 
sented with  the  confident  anticipation  that  it  will  maintain  its  position  in  the  front  rank  of 
text-books  for  the  student,  and  of  works  of  reference  for  the  practitioner,  while  its  exceedingly 
moderate  price  places  it  within  the  reach  of  all. 


The  seveuth  editioa  is  before  the  world  as  the  last 
word  ot  surgical  scieace.  There  may  be  tnoaographs 
which  excel  it  upon  certain  points,  but  as  a  con- 
spectus upon  surgical  principles  aud  practice  it  is 
unrivalled,  it  will  well  reward  priictitioners  to 
read  it,  for  It  has  been  a  peculiar  province  of  Mr. 
Eiichsen  to  demonstrate  the  absolute  interdepend- 
ence of  medical  and  surgical  science  We  need 
scarcely  add,  in  conclusion,  that  we  heartily  com- 
mend the  work  to  students  that  they  may  be 
grounded  in  a  sound  faith,  and  to  practitioners  as 
an  invaluable  guide  at  the  bedside. — Am.  Practi- 
tioner, April,  1878. 

It  is  no  idle  compliment  to  say  that  this  is  the  Oest 
edition  Mr.  Erichsen  has  ever  produced  of  his  well- 
known  book.  Besides  inheriting  the  virtues  of  i's 
predecessors,  it  possesses  excellences  quite  its  own. 
Having  stated  that  Mr.  Erichsen  his  incorporated 
into  this  edition  every  recent  improvement  in  the 
science  and  art  of  surgery,  it  would  be  a  supereroga- 
tion to  give  a  detailed  criticism.  In  short,  we  nn- 
hesitatiugly  aver  that  we  know  of  no  other  single 
work  where  the  student  and  practitioner  can  gain  at 
once  so  clear  an  insight  into  the  principles  of  surgery, 
and  so  complete  a  knowledge  of  the  exigencies  of 
surgical  practice.— io'/idon.  Lancet,  Feb.  14,  1878 

For  the  past  twenty  years  Erichsen's  Surgery  has 
maintained  its  place  as  the  leading  text- book,  not  only 
in  this  country,  but  in  Great  Briiaiu.  That  it  is  able 
to  hold  its  ground,  is  abundantly  jiroveu  by  the  tho- 
roughness with  which  the  present  edition  has  been 
revised,  and  by  the  large  amount  of  valuable  mate- 
rial thai  has  been  added.  Aside  from  this,  cne  hun- 
dred and  tifty  new  illustrations  have  been  inserted, 
including  quite  a  number  of  microscopical  appear- 
ances of  pathol>gical  processes.  e>o  marked  is  this 
change  for  the  better,  that  the  work  almost  appears 
as  an  entirely  new  one. — Med.  Record,  Feb.  23,1878. 


Of  the  many  treatises  on  Snrjfery  which  it  has  been 
our  task  to  study,  or  our  pleasure  to  read,  there  is  none 
which  in  all  points  has  satisfied  us  so  well  as  the  classic 
treatise  of  Erichsen.  His  polished,  clear  style,  his  free- 
dom from  prejudice  and  hobbies,  hisunsurpassed  grasp 
of  his  subject,  and  vast  clinical  experience,  qualify  him 
admirably  to  write  a  model  text-book.  When  we  wish, 
at  the  least  cost  of  time,  to  learn  the  most  of  a  topic  in 
surgery,  we  turn,  by  preference,  to  his  work.  It  is  a 
pleasure,  therefore,  to  see  that  the  appreciation  of  it  is 
sreneral,  and  has  led  to  the  appearance  of  another  edi- 
tion.— M<:d.  and  Surg.  Jieporlfr,  Feb.  2, 1878. 

Notwithstanding  the  increase  iu  size,  we  observe  that 
much  old  matter  has  been  omitted.  The  entire  work 
has  been  thoroughly  written  up,  and  not  merely  amend- 
ed by  a  few  extra  chapters  A  great  improvement  has 
beeu  made  in  the  illustrations.  One  hundred  and  fifty 
new  ones  have  been  added,  and  ntauy  of  the  old  ones 
have  been  redrawn  The  author  highly  ajipreciates  the 
favor  with  which  his  work  has  been  received  by  Ameri- 
can surgeons,  and  has  endeavored  to  render  his  latest 
edition  more  than  ever  worthy  of  their  approval.  That 
he  has  sucreeded  admirably,  must,  we  think,  be  the 
general  opinion.  We  heartily  recommend  the  book  to 
both  student  and  practitioner. — N.  1'.  Med.  Journal, 
Feb.  1878. 
Erichsen   has   stood   so  prominently  forward   for 

I  years  as  a  writer  on  Surgery,  that  his  reputation  is 
world  wide,  and  his  name  is  as  familiar  to  the  med- 
ical student  as  to  the  accomplished  and  experienced 

!  surgeon.     The  work  is  not  a  reprint  of  former  edi-. 

i  tions,  but  has  in  many  places  been  entirely  rewrit- 

i  ten.  Recent  improvements  in  surgery  have  not  es- 
caped his  notice,  various  new  operations  have  been 
thoroughly  analyzed,  and   their  merits  thoroughly 

1  discussed.     One  hundred   and  fifty  new   wood-cuts 

I  add  to  the  value  of  this  work. — iV'.  O.  Med.  and  Surg. 

I  Journal,  March,  1878. 


JJOLMES  {^TIMOTHY),  M.D., 

mJ.  Srirgeon  to  St.  George's  Hoxpital,  London. 

SURGERY,  ITS  PRINCITLES  AND  PRACTICE.  In  one  hand- 
some octavo  volume  of  nearly  1000  pages,  with  411  illustrations.  Cloth,  $6 ;  leather,  $7. 
{Just  Issued.) 


This  is  a  work  which  has  been  lookedfor  on  both 
si.les  ofthe  Atlantic  with  much  interest.  Jlr.  Holmes 
Is  a  surgeon  ot  large  and  varied  experience,  and  one 
of  the  best  known,  and  perhaps  the  most  brilliant 
writer  upon  surgical  subjects  in  England.  It  is  a 
book  for  students — and  an  admirable  one — and  for 
the  busy  general  practitioner  J  l  will  give  a  student 
all  the  knowledge  needed  to  pass  a  rigid  examina- 
tion. The  book  fairly  j  ustifles  the  high  expectations 
that  were  formed  )f  it.  Its  style  is  clear  and  forcible, 
even  brilliant  at  times,  and  the  conciseness  needed 
to  bring  It  within  its  [>roper  limits  has  not  impaireo 


its  force  and  distinctness. — N.  Y.  Med.  Record,  April 
U,  1H76. 

It  will  bo  found  a  most  excellent  epitome  of  sur- 
gery by  the  general  practiiioner  wlio  has  not  the 
time  togiveattention  to  more  minute  and  extended 
works  and  to  the  medical  student.  In  fact,  we  know 
of  no  one  we  can  more  cordially  recommend.  The 
author  has  succeeded  well  in  giving  a  plain  and 
practical  account  of  each  surgical  injury  and  dis- 
ease, and  of  the  treatment  which  is  most  com- 
monly advisable.  It  will  no  doubt  become  a  popu- 
lar work  in  the  profession,  and  especially  as  a  text- 
book.—  Cincinnati  Med.  News,  April,  1876. 


ASHTON  ON  THE  DISEASES,  INJURIES,  andMAL- 
FOtlilATlONS  OF  THE  RECTUM  AND  ANUS: 
with  remarks  on  Haliitnal  Con.-tipation.  Second 
Aiueric^in,  from  the  fourth  and  enlarged  London 
Edition.  With  ill  ustraiions.  In  one  8vo  vol.  of 
28/   pages,  cloth,. $a  20. 


SARGENT  ON  BANDAGING  AND  OTHER  OPERA- 
TIONS OF  MINOR  SURGERY.  New  edition,  with 
an  additional  chapter  on  Military  Surgery.  One 
l'2mo.  vol.  ot  383  pag3s  with  18 1  wood-cuts.  Cloth, 
.$1  7J. 


B 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Ophthalmology).      29 
fJAMILTON  [FRANK  H.),  M.D., 

*-L  Professor  nf  Fractures  and  Dislocations,  Ac,  in  Bellevue  Hasp.  Med.  College,  New  York. 

A  PRACTICAL  TREATISE  ON   FRACTURES  AND  DISLOCA- 

TIONS.  Fifth  edition,  revised  and  improved.  In  onelargeand  handsome  octavo  volume 
of  nearly  800  pages,  with  344  illustrations.  Cloth,  $5  75;  leather,  $6  75.  {Laie/y  Ismcd.) 

This  work  is  well  known,  abroad  as  well  as  at  home,  asthe  highest  authority  on  its  important 
subject — an  authority  recognized  in  the  courts  as  well  as  in  the  schools  and  in  practice — and 
again  manifested,  not  only  by  the  demand  for  a  fifth  edition,  but  by  arrangements  now  in  pro- 
gress for  the  speedy  appearance  of  a  translation  in  Germany.  The  repeated  revisions  which  the 
author  has  thus  had  the  opportunity  of  making  have  enabled  him  to  give  the  mostcareful  consid- 
eration to  every  portion  of  the  volume,  and  he  has  sedulously  endeavored  in  the  present  issue, 
to  perfect  the  work  by  the  aid  of  his  own  enlarged  experience,  and  to  incorporate  in  it  whatever 
of  value  has  been  added  in  this  department  since  the  issue  of  the  fourth  edition.  It  will  there- 
fore be  found  considerably  improved  in  matter,  while  the  most  careful  attention  has  been  paid 
to  the  typographical  execution,  and  the  volume  is  presented  to  the  proftssion  in  the  confident 
hope  that  it  will  more  than  maintain  its  very  distinguished  reputation. 

There  i.s  no  better  work  on  the  subject  in  existence  i  of  its  teachings,  but  also  by  reason  of  the  medico-lepal 
than  that  of  Dr.  Hamilton.  It  should  be  in  the  posses-  beariofrs  of  the  cases  of  which  it  treats,  and  which  have 
sion  of  every  general  practitioner  and  surgeon.  — TAe  recently  been  the  subject  of  usefulpapers  by  Ur  Hamil- 
Am.  Jnurn.  of  Obstetrics.?  eh.  l^'iQ.  ton  and  others,  is  sufficiently  obvious  to  every  one.  The 

The  value  of  a  work  like  this  to  the  practical  physi-    present  volume  seems  tn  amply  fill  all  the  requisites, 
cian  and  surgeon  can  hardlvbeover-estimated.and  the     ^'^  7°  f.*f«7  recommend  it  as  the  best  of  its  kind  in 
necessity  of  havinst  such  a  book  revised  to  the  latest    f^e  ^'^'^^l^?:  lan-uage.  and  notexcelled  in  any  other, 
dates, notmereiyonaccountofthepracticalimportanceK''«'''«-^/-^*'''-'<'"S«"'^J^««««^^«ease,  Jan. 1876. 

ROWXE  {EDGAR  A.), 

Surgeon  to  the  Liverpool  Eye  and  Ear  Infirmary,  and  tothe  Dispensary  for  Skin  Diseases. 

HOW  TO  USE  THE  OPHTHALMOSCOPE.     Being  Elementary  In- 

structionsin  Ophthalmoscopy,  arranged  for  the  Use  of  Students.  With  thirty-five  illustra- 
tious.     In  one  small  volume  royal  12mo.  of  120  pages  :  cloth,  $1.     {Now  Ready.) 

ffARTER  {R.  BRUDENELL),  ER.C.S., 

'-^  0 ij'ittialmic  Surgeon  fo  St.  George's  JJosp^al,  etc. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  EYE.    Edit- 

ed,  with  test-types  and  Additions,  by  John  Green,  M.D.   (of  St.  Louis,  Mo.).     In  one 
handsome  octavo  volume  of  about  500  pages,  and  124  illustrations.    Cloth,  $3  75 .    {Just 
Issued.) 
It  is  with  j^reat  pleasure  that  we  can  endorse  the  work  t  chapter  is  devoted  to  a  discussion  of  the  usesand  selec- 
as  a  most  valuable  contribution  to  practical  ophthal- 1  tion  ofspectacles,  and  is  admirably  compact,  plain,  and 
molopy.  Mr.  Carter  neverdeviates  from  the  end  he  has  |  useful,  especially  the  paragraphs  on  the  treatment  of 
in  view,  and  pre.sents  the  subjectin  a  clear  and  concit-t    presbyopia  and  myopia.  In  conclusion,  our  thanks  are 
manner,  easy  of  comprehension,  and  lience  the  mort  !  due  the  author  for  many  useful  hints  in  the  great  sub- 
valuable.   We  would  especially  commend,  however,  as  jject  of  ophthalmic  surgery  and   therapeutics,  afield 
worthy  of  high  praise,  the  manner  in  which  the  thera-  j  whereof  late  years  we  glean  but  a  few  grains  of  .sound 
peutiijs  of  disease  of  the  eye  is  elaborated,  for  here  th«  I  wheat  from  a  mass  of  chaff. — JS'evj  York  MtdicalJtecord, 
author  is  particularly  clear  and  practi<al.  where  otliei  j  Oct.  23, 1875. 
writers  are  unfortunately  too  often  deticient.  The  final  1 

Vi/'ELLS  [J.  SOELBERG), 

'  '  Professor  of  Ophthalmology  in  King's  College  Hospital,  Ac. 

A  TREATISE  ON    DISEASES  OF  THE  EYE.     Third  American, 

from  the  Fourth  and  Revised  London  Edition,  with  additions  ;  illustrated  with  numerous 
engravings  on  wood,  and  six  colored  plates.  Together  with  selections  from  the  Test-types 
of  Jaeger  and  Snellen.    In  one  large  and  very  handsome  octavo  volume.    {Preparing.) 

l\JETTLESniP  [ED  WA Rr/^F.R. C.S., 

-^  '  OpIdK'iimic  Svrg.  and  Led.  on  Opiith.  Surg   at  St.  Thomas'  Hospital,  London. 

MANUAL    OF    OPHTHALMIC    MEDICINE.     Jn  one  royal  12mo. 

volume  of  over  350  pages,  with  89  illustrations.     Cloth,  $2.     {Just  Heady.) 

SUMMARY  OF   CONTENTS. 

PART  .  Mmyis  of  Diagnosis.  Chap.  I.  Leading  Symptoms.  Chap.  II.  External  Exam- 
ination of  the  Eye.  Chap.  111.  Examination  of  the  Eye.  PART  II.  Clinical  Dtviston. 
Chup  IV.  Dise.ises  of  the  Ey'lids.  Chap.  V.  Diseases  of  tho  Lachrymal  Apjiar.'itus.  Chap. 
VL  Diseases  of  the  Cor  junctivH.  Chap.  Vl[.  Diseases  rf  the  Cornea.  Chap.VHl.  Diffuse 
Keratitis.-  Chap.  IX  Iritis  Chap.  X.  Disea.'es  of  the  CiHary  Kegion.  Chap.'  XI.  Injuries. 
Chap.  XII  Cataract.  Chap.  XIII  Diseases  of  the  Choroid.  Chap.  XIV.  Diseases  of  the 
Ketina.  Chap.  XV  Diseases  of  the  Vitreous.  Chap.  XVI.  Glaucoma  Chap.  XVU.  Dis- 
eases of  the  Optic  JNerve.  Chap.  XVIII.  Tumors  and  New  (Jrowtbs.  Chap.  XIX.  Errors  of 
llefraction  ami  Accommodation  Chap.  XX.  Strabismus  and  Paralysis.  Chap.  XXI.  Opera,- 
tions.  PART  fll.  Difeosci  of  the  Ktje  in  Relation  tj  Geinral  Diseases.  Chap.  XXII.  A. 
General  Disease;.  B.  Local  Disease  at  a  Distance  from  the  Eye.  C.  The  Eye  Sharing  in  a 
Local  Disease  of  the  Neighboring  Parts.     Formulae,  etc.     Index. 

L.vnRKXCE'S  HANDl'BdOK  OF  OJ'Hl  H  AL.MIC  i  LA  AfbOX  S  INJURIES  TO  TH  K  EVE.  ORBIT, 
SUKfi  BUY,  for  iliG  nse  of  Hractitiooers.  Second  |  aNL)  EVELIlJS:  tteir  Iinmediale  arid  Remote 
editioa,  revised  and  enlarged  With  nnmerous  l  Etfecls.  With  about  one  linndred  illiisf rationH. 
illnRlra.iion8.  In  oue  very  li.iudsouie  octavo  vol- j  lu  ono  ver>  haud.^ouie  ottavu  volume,  cloth, 
ume,  cUlh,  %i  lo.  I      it>J  Cu. 


30    Henry  C.  Lea's  Son  &  Co.'s  Publications — (Med.  Jurisprudence). 


J?URNETT  (CHARLES  H.),  M.A  ,M.D., 

-*--'  Aurj,'.  Surg  to  the  Preab.  Hasp.,  Surgeon-in-t  karge  of  the  J-nfir  far  Dis  of  the  Ear,  Phila. 

THE    EAR,   ITS    ANATOMY.   PHYSIOLOGY,   AND   DISEASES. 

A  Practical  Treatise  for  the  Use  of  Medical  Students  and  Practitioners.     In  one  hand- 
some octavo  volume  of  615  pages,  with  eighty -seven  illustrations  :  cloth,  $4  50  ;  leather, 
$5  50.      {Now  Ready.) 
Rocent  progress  in  the  investigation  of  the  structures  of  the  ear,  and  advances  made  in  the 
modes  of  treating  its  diseases,  wouldseein  to  render  desirable  a  nevr  woik  in  which  all  the  re- 
sources of  the  most  advanced  science  should  Ijp  placed  a*  the  dispo.«al  of  the  practitioner.  This 
it  has  been  the  aim  of  Dr.  Burnett  to  accomplish,  and  the  advantages  which  he  has  enjoyed  in 
the  special  study  of  the  subject  are  a  guarantee  that  the  result  of  his  laborb  will  prove  of  service 
to  the  profession  at  large,  as  well  as  to  the  specialist  in  this  deiiartment. 

Forenioi-t  amung  the  numeroos  recent  cnutrihu  j  medical  studeut,  and  its  study  will  wpU  repay  tlie 
tions  to  aural  literatiir>  will  bi-  ranked  this  work  I  bii.sy  practitioner  i  a  the  pleasure  he  will  derive  from 
of  Dr.  Burnett.  It  i.s  impossible  to  do  juslic«  to  I  the  agreeable  style  in  which  many  otherwise  dry 
this  volume  of  over  600  pages  in  a  nece-'arily  brief  anci  mostly  unknown  subjects  are  treated.  To  (he 
notice.  It  must  saffice  to  add  that  the  bool  is  pro-  \  specialist  tlie  work  is  of  the  highest  value,  and  bis 
fusely  and  accurately  illusirated,  the  references  are  '  sense  of  gratitude  to  Dr.  Burnett  will  we  hope,  be 
conscieoti'  usiy  acknowledged,  w  bile  the  result  has  !  proportionate  to  the  amount  of  benefit  he  can  obtain 


been  to  produce  a  treatise  which  will  liencefortQ 
rank  with  the  classic  writings  of  Wilde  and  Von 
Trolsch.  — jTAe  Loud.  Practitioner,  May,  1879 

On  account  of  the  great  advances  which  have  hoen 
made  of  late  years  in  otology,  and  of  the  increased 
intfrest  manifested  in  it,  the  medical  profes^ion  will 
welcome  this  new  woik,  which  preseuls  clearly  and 
concisely  its  present  aspect,  whilst  clearly  indi- 
cating tlie  direction  in  which  further  resear<-hes  can 
be  most  profiiably  carried  on.  Dr.  Burn  tt  from  his 
own  matured  experience,  and  availing  himself  of 
the  observations  and  discoveries  of  others,  has  pro- 
duced a  work,  which  as  a  text-book,  stands /«ci/e 
•princep.'i  \a  our  language.  We  had  marked  several 
pa-sages  as  well  wonby  of  quotation  and  the  atten- 
tion of  the  general  practitioner,  but  their  number  and 
the  space  at  our  command  forbid.  Perhaps  it  is  liet-' 
ter,  as  the  book  ought  to  be  in  the  hands  of  every 


from  the  careful  study  of  the  book,  and  a  constant 
reference  to  its  trustworthy  pages. — Edinbu  gh 
Med.  Jour.,  Aug.  1678. 

The  book  is  designed  especially  for  the  use  of  stu- 
d'ints  and  general  practitioners,  and  places  at  their 
disposal  much  valuable  material.  Such  a  book  as 
the  present  one,  we  think,  baslougbeen  needed, and 
we  may  congratulate  the  author  on  his  success  in 
lllliug  the  gap.  Bolh  s.:udent  and  practitioner  can 
study  the  work  with  a  gr^at  deal  of  benefit.  It  is 
profusely  and  beautifully  Illustrated.— iV.  Y.  Hon- 
pital  Gazette,  Oct   15,  1877. 

Dr.  Burnett  is  to  be  com  mended  for  having  written 
the  best  book  on  the  subject  in  the  English  language, 
and  es^pecially  for  the  care  and  attfulion  he  has 
given  to  the  scientiflc  side  of  the  subject. — iV.  ¥. 
Med.  Journ.,  Dec.  1877. 


T 


'AYLOR  [ALFRED    S.),M.D., 

Lecturer  on  Med.  Juri.9p.  and  Chemistry  in  Ouy's  Hospital. 

POISONS  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND 

MEDICINE.     Third  American,  from  the  Third  and  Revised  English  Edition.     In  one 
large  octavo  volume  of  860  pages;  cloth,  $5  50;  leather,  $6  50.      {Just  Issued.) 


The  present  is  based  upon  the  two  previous  edi- 
tions; "'but  the  coinpieteievision  rendered  necessary 
by  time  has  converted  it  into  a  new  work."  This 
statement  from  the  preface  contains  all  that  it  is  de- 
sired to  know  in  reference  to  the  new  edition  The 
works  of  this  author  are  already  in  the  library  of 
every  physician  who  is  liable  to  be  called  upon  for 
medico-leg.U  testimony  (and  what^neis  not?),  so  thai 
all  that  is  required  to  be  known  about  the  present 
book  is  that  the  author  has  ket>t  it  abreast  with  the 
times.  What  makes  it  now, 'as  always,  especially 
valuable  to  the  prac.ilioner  is  its  conciseness  ana 
practical  character,  only  those  poisonous  substances 

Tor  THE  SAME  AUTHOR. 

MEDICAL  JURISPRUDENCE. 

by  John  J.  Reese,  M.D.,  Prof  of  Med 
octavo  volume  of  nearly  900  pages.     Clo 

To  the  members  of  the  legal  and  medical  profes- 
iion.  It  is  uuuece.-sary  to  say  anything  commeuda- 
;ory  of  Taylor's  Medical  Jurisprudence.  We  might 
iS  well  undertake  to  speak  of  the  merit  ofOhitly's 
Pleadings.— CVt'c«j/"  Legal  News,  Oct.  ItJ,  187.S. 

It  is  beyond  question  the  most  attractive  as  well 
18  most  reliable  manual  of  medical  jurisprudence 
published  in  the  English  language.  — /Im. /o?/9-««/ 
1/  SyphVography,  Oct.  187;i. 

It  isaltogetbersupertiuousfor  us  to  offer  anything 
;u  behalf  of  a  work  on  medical  j  uris])  rude  nee  by  an 
luthor  who  is  almost  universally  esteemed  to  be  the 


being  described  which  give  rise  to  legal  Investiga- 
tions.—r/i«  Clinic,  Nov.  6,  1S7.'5. 

Dr.  Taylor  hai-  brought  to  bear  on  the  compilation 
of  this  volume,  stores  of  learning,  experience,  and 
practical  acquaintance  with  Lis  subject.,  probably  (ur 
beyond  what  any  other  living  authority  on  toxicol- 
ogy could  have  amassed  or  uiilized.  He  has  fully 
sustained  his  retuitation  by  the  consummate  skill 
aud  legal  acumen  he  has  displayed  in  the  arrange- 
ment of  the  subject-matter,  and  the  result  is  a  work 
on  I'oisoos  which  will  be  indispensable  to  every  stu- 
deut or  practitioner  in  lawand  medicine — The  Dub- 
Lin  Journ.  if  Med  So..,  Oct.  187.'). 


Seventh  American  Edition.  Edited 

Jurisp.  in  the  Univ.  of  Penn.     In  one  large 

th,  $5  00;  leather,  $6  00.  {Lately  lssn»fl.) 
bdst  authority  on  this  specialty  in  our  language.  On 
thispoiut,  however,  we  will. -^ay  thai  wee onsiderD I. 
Taylor  to  be  the  safest  medico-legal  authority  tofol- 
low,  in  general,  with  which  we  are  acquainted  in  any 
language. —  Va   Clin.  Record,  Nov.  187.1 

T  his  la.st  edition  of  the  Manual  is  probably  the  best 
of  all, as  it  coniai  us  more  material  and  is  w  orked  up 
to  the  latest  views  of  the  author  as  expressed  i  n  the 
last  edition  of  the  Principles.  Dr.  Keese,  the  editor 
of  the  Manual,  has  done  everything  to  make  hiB 
work  accept  able  to  his  medical  countrymen. — N.  Y. 
Med.  Record,  Jan.  1.5,  1874. 


TiY  THE  SAME  AUTHOR. 

THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURISPRU- 

DENCE.     Second  Edition,  Revised,  with  numerous  Illustrations.    In  two  large  octavo 

volumes,  cloth,  $10  00;  leather,  $12  00 
This  "reat  work  i.s  now  recognized  in  England  as  the  fullest  and  most  authoritative  treatise  on 
ivery  department  of  its  important  subject.  In  laying  it,  in  its  improved  form,  before  the  A  mer- 
can  profession,  the  publisher  trusts  that  it  will  assume  the  same  position  in  this  country. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — CMisnellaneous).       31 


J>0 BERTS  (  WILLIAM),  M.D., 

'-*'  Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  etc. 

A  PRACTICAL  TREATISE    ON  URINARY  AND  RENAL  DIS- 

EASES,  including  Urinary  Deposits.  Illustrated  by  numerous  cases  and  engravings.  Third 
American,  from  the  ThirdRevised  and  Enlarged  London  Edition.  In  one  largt  and 
handsome  octavo  volume  of  over  600  pnges.     Cloth,  $4.     {Jvst  Beady.) 

rfHOMPSON  [SIR  HENRY), 

■*•  Surgeon  and  Professor  of  Olinicnl  Surgery  to  University  College  Hospital . 

LECTURES  ON  DISEASES  OF  THE  URINARY  ORGANS.  With 

illustrations  on  wood.     Second  American  from  the  Third  English  Edition.    In  one  neat 
octavo  volume.     Cloth,  $2  25.     (^Just  Issued.) 


B 


7  THE  SAME  AUTHOR.  

ON  THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OF 

THE  URETHRA  AND  URINARY  FISTULiE.  With  plates  and  wood-cuts.  From  the 
third  and  revised  English  edition.  In  one  very  handsome  octavo  volume,  cloth,  $3  50. 
(  hutt:ly  P ublished.) 

rrUKE  [DANIEL  HACK),  M.D  , 

■M.  Joint  author  of  "  The  Manual  of  P.'.ychological  Medicine,^^  &c. 

ILLUSTRATIONS  OF  THE  INFLUENCE  OF  THE  MIND  UPON 

THE  BODY  IN  HEALTH  AND  DISEASE.  Designed  to  illustrate  the  Action  of  the 
Imagination.  In  one  handsome  octavo  volume  of  416  pages,  cloth,  $3  25.  [Lately  Issued.) 

-DLANDFORD  [G.  FIELDING),  M.D.,  F.R.G.P., 

.»-'  Lecturer  on  Psychological  Medicine  at  the  School  of  St.  George's  Hospital,  &c. 

INSANITY  AND  ITS  TREATMENT:  Lectures  on  the  Treatment, 

Medical  and  Legal,  of  Insane  Patients.  With  a  Summary  of  the  Laws  in  force  in  the 
United  States  on  the  Confinement  of  the  Insane.  By  Isaac  Ray,  M.  D.  In  one  very 
handsome  octavo  volume  of  471  pages ;  cloth,  $3  25. 


It  satisfies  a  waut  which  must  have  been  sorely 
felt  by  the  bu^y  geueralpi-aclitioneroof  thiscouutry. 
it  takes  the  form  of  a  manual  of  clinical  descriinioii 
of  the  various  forms  of  insauiiy,  with  a  description 
of  the  mode  of  examining  persons  stispected  of  in- 
Binity.  We  call  particular  attention  to  this  feature 
of  the  book,  as  giviugit  a  unique  value  to  the  gene- 
ral practitioner.  If  we  pass  from  theoretical  conside- 
rations to  descriptions  of  the  varieties  of  insanity  as 


actually  seen  in  practice  and  the  appropriate  treat- 
ment for  them,  we  find  in  Dr.  Blattdfurd's  work  a 
considerable  advance  over  previous  writings  on  the 
subject.  His  pictures  of  the  various  forms  of  mental 
disease  are  so  clear  and  good  that  no  reader  can  fail 
to  be  struck  with  their  superiority  to  those  given  in 
II di nary  manuals  in  the  English  language  or  (so  far 
as  our  own  reading  extendsjinany  other. — London 
Practitioner,  Feb.  187 J. 


f  EA  [HENRY  C). 

SUPERSTITION   AND   FORCE:    ESSAYS   ON   THE   WAGER   OF 

LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.     Third  Revised 
and    Enlarged   Edition.    In  one  handsome  royal  12mo.  volume  of  552  pages.     Cloth 
$2  50.      (Just  Ready) 
The  appearance  of  a  new  edition  of  Mr.  Henry  C.  I  polemic.     Though    he   obviously  feels   and   tliinks 

Lea's  "  Jiuperstition  and  Force"  is  a  s^gu  tliat  our    strongly,    he    succeeds    in    attaining    impartiality. 

highest  scholar-  hip  is  not  without  honor  in  its  na-     \Vhel;l  er  looked  on  as  a  picture  or  a  mirror,  a  work 

li /e  country.    Mr.  Lea  has  met  every  fresh  demand    such   as    this    has   a   lasting   value. — Lippincott's 

for  his  work  with  a  careful  recioion  of  it,  and  the     Magazine,  Oct.  lS7S. 

pre.sent  eaiiion  is  not  only  fuller  and,  if  possible,        nr.  Lea's  curious  historical  monographs,  of  which 


more  accurate  llian  either  of  the  preceding,  but, 
from  the  thorough  elaboration  is  more  like  a  har- 
monious concert  and  less  like  a  batch  of  studies. — 
The  ^'ation,  Aug.  1,  1878. 

Many  will  ba  tempted  to  say  that  this,  like  the 
'•Declineaud  Fall,"isone  of  the  uncriticizable  books 
Its  facts aie  innumerable, its  deductions  simple  and 
inevitable,  and  its  chevaux-dt-frise  of  references 
bristling  and  dense  enough  to  make  the  keenest, 
stoutest,  and  best  equipped  assailant  think  twice 
before  advancing.  Nor  is  there  anything  contro- 
versial in  it  to  provoke  assiult.     The  author  is  uo 


one  of  the  most  important  is  here  reproduced  in  an 
enlarged  form,  have  given  him  an  unique  position 
among  Knglisli  and  American  schnlars.  He  is  dis- 
tinguished for  his  recondite  and  alHuent  learning 
his  power  of  exhaustive  historical  analysis,  tlie 
breadth  and  accuracy  of  his  rese.irchis  among  the 
rarer  sources  of  knowledge,  the  gravity  and  temper- 
ance of  his  statements,  combined  with  singular 
earnestness  of  conviction,  and  iiis  warm  attachment 
to  the  cau^e  of  human  freedom  and  intellectual  pro- 
gress.— N.  Y.  Tribune,  Aug.  9,  1578. 


B 


Y  THE  SAME  AUTHOR.    (Lately  Published.) 

STUDIES  IN  CHURCH  HISTORY— THE  RISE  OF  THE  TEM- 
PORAL POWER— BENEFIT  OF  CLERGY— EXCOMMUNICATION.  In  one  large 
royal  12mo.  volume  of  516  pp.;  cloth,  $2  75. 

The  story  was  never  told  more  calmly  or  with,  lasapeculiariraportancefortlieEnglisb  student. and 
gr3ater  learning  or  wiser  thought.  We  doubt,  indeed,  |  i-t  a  chapter  on  Ancient  Law  likely  to  he  regarded  as 
if  any  other  study  of  this  field  can  be  compared  with  j  llual.  We  can  hardly  pas^  frum  our  mo  u  lion  of  such 
ttiis  for  clearness,  accuracy,  and  power.  —  Chicago  works  as  these — with  which  that  on  "Sacerdotal 
Examiner,  Dec.  1S70.  Gelibicv"  should  bo  i ncludad—witbont  noting  f  be 

Mr  Lea's  latest  work,"  Studiesin  Church  History,"    Hte'-*t'y  phenomenon  that  the  head  of  one  oi  t  he  firsf 
fully  sustains  the  promise  of  the  first.   It  deals  with     American  houses  isalso  the  writer  of  some  of  its  most 
three    subjects- the  Temporal    Power,    Benefit   of  hnsmal  books.-Z,.)n</o7i  .K^ewaum,  Jan.  7   1871. 
Clergy,  and  Excommunication,  the  record  of  which  | 


32 


Henry  C.  Lea's  Sox  &  Co.'s  Publicatioxs. 


IXDEX   TO    CATALOGUE. 


American  Joarnal  of  the  Medical  Sciences 
Allen's  Anatomy   ..... 
Aaatomical  Atlas,  by  Smith  and  Horner 
Ashton  on  the  Rectum  and  Anus 
Atttieid'g  Chemistry    .... 
A  =  hwell  on  Diseases  of  Females 
Ashhurst's  Surgery        .... 
Browne  on  Ophthalmoscope  . 
Browne  on  the  Throat    .... 
Burnett  on  the  Ear         .... 
Barnes  on  Diseases  of  Women 
Barnes'  Midwifery         .... 
Bellamy's  Surgical  Anatomy 
BryantsPractice  of  Surgery 
Bloxam's  Chemistry     .... 
Blandford  on  Insanity  .... 
Basham  on  Kenal  Diseases  . 
Brinton  on  the  Stomach 
Barlow's  Practice  of  Medicine    . 
Bowman's  (John  E.)  Practical  Chemistry 
Bristowe's  Practice         .... 
Bumstead  on  Venereal 
Bumstead  and  Callerier'sAtlasof  Venere 
carpenter's  Human  Physiology 
(;  irpenter  on  the  Use  and  Abuse  of  Alcohol 
Cornil  and  Eanvier        •.        .        .         . 

Carter  on  the  Eye 

Cleland's  Dissector        .... 
Classen's  Chemistry       .... 
Clowes'  Chemistry         .... 
Century  of  American  Medicine    . 
Chadwick  on  Diseases  of  Women 
Charcot  on  the  Xerrous  System   . 
Chambers  on  Diet  and  Regimen  . 
Christison  and  Griffith's  Dispensatory 
Churchill's  System  of  Midwifery 
Churchill  on  Puerperal  Fever 
Condie  on  Diseases  of  Children  . 
Cooper's  (B.  B.)  Lectures  on  Surgery 
Callerier's  Atlas  of  Venereal  Diseases 
Cyclopaedia  of  Practical  Medicine 
Duncan  on  Diseases  of  Women    . 
Dalton's  Human  Physiology        .        . 
Davis's  Clinical  Lectures 
Dewees  on  Diseases  of  Females  . 
Druitt's  ModernSurgery 
Dnnglison's  Medical  Dictionary 
Ellis's  Demonstrations  in  Anatomy 
Erichsen's  System  of  Surgery     . 
Emmet  on  Diseases  of  Women 
Far'iuharson's  Therapeutics 

Foster's  Physiology 

Fenwick's  Diagnosis      .... 
Finlayson's  Cliuical  Diagnosis 
Flint  on  Respiratory  Organs 
Flint  on  tiie  Heart         .... 
Flint's  Practice  of  Medicine. 

Flint's  Essays 

Flint's  Clinical  Medicine 

Flint  on  Phthisis 

Fliat  on  Percussion        .... 
Fothergill's  Handbook  ofTreatment  . 
Fothergill's  Antagonism  of  Therapeutic  Age 
Fiwnes's  Elementary  Chemistry 
Fox  on  Diseases  of  the  Skin 
Fuller  on    the  Lungs,  &c.     . 
Green's  Pathology  and  Morbid  Anatomy 
Greene's  Medical  Chemistry 

Gibson's  Surgery 

Gluge's  Pathological  Histology,  by  Leidy 

Gray's  Anatomy 

Galloway's  Analysis       .... 

Griffith's  (R.  E.)  Universal  Formulary 

Gross  on  Urinary  Organs 

Gross  on  Foreign  Bodies  in  Air-Passages 

Gross's  System  of  Surgery   . 

Habershon  on  the  Abdumen  . 

Hamilton  on  Dislocations  and  Fractures 

Hartshorne's  Essentials  of  Medicine  . 

Hartsnorne's  Conspectus  of  the  Medical  Sci 

Hartshorne's  Anatomy  and  Physiology 

Hamilton  on  Xervous  Diseases    . 

Heath's  Practical  Anatomy 

Hoblyn'8  Medical  Dictionary     . 


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Hodge  on  Women  .... 

Hedge's  Obstetrics         .... 

Holland's  Medical  Xotes  and  Reflections 

Holmes's  Surgery  . 

Holden's  Landmarks 

Horner's  Anatomy  and  Histology 

Hudson  on  Fever   .... 

Hill  on  Venereal  Diseases    . 

Hillier's  Handbook  of  Skin  Diseases 

Jones  (C.  Haudheid)  on  Nervous  Disorders 

Knapp's  Chemical  Technology   . 

Lea's  Superstition  and  Force      .         . 

Lea's  Studies  in  Church  History 

Lee  on  Syphilis 

Lincoln  on  Electro-Therapeutics 

Leishman's  Midwifery 

La  Roche  on  Yellow  Fever. 

La  Roche  on  Pneumonia,  &c. 

Laurence  and  Moon's  Ophthalmic  Surgery 

Lawson  on  the  Eye       .... 

Lehmann's  Physiological  Chemistry,  2  vols. 

Lehmann's  Chemical  Physiology 

Ludlow's  JIanual  of  Examinations 

Lyons  on  Fever     .... 

Medical  Xews  and  Abstract 

Morris  on  Skin  Diseases 

Meigs  on  Puerperal  Fever    . 

Miller's  Practice  of  Surgery 

Miller's  Principles  of  Surgery     . 

Montgomery  on  Pregnancy 

Xettleship's  Ophthalmic  Medicine 

Xeill  and  Smith's  Compendium  of  Med.Scien 

Obstetrical  Journal        .... 
;  Parry  on  Extra-Cterine  Pregnancy 

Pavy  on  Digestion 

Parrish's  Practical  Pharmacy     .        . 
Pirrie's  System  of  Surgery  . 

Playfair's  Midwifery     .... 
Qnain  and  Sharpey's  Anatomy,  by  Leidy 

Reynolds'  System  of  Medicine    . 

Roberts  on  Urinary  Diseases 
Ramsbotham  on  Parturition         .        .  • 

Remsen'a  Principles  of  Chemistry 

Rigby's  Midwifery         .... 

Rodwell's  Dictionary  of  Science  . 

Siimson's  Operative  Surgery 

Swayne's  Obstetric  Aphorisms    . 

Seller  on  the  Throat       .... 

Sargent's  Minor  Surgery 

Sharpey  and  Qnain'e  Anatomy,  by  Leidy 

Skey's  Operative  Surgery     . 

Slade  on  Diphtheria      .... 

Schiifer's  Histology        .... 

Smith  (J  L.)  on  Children      ... 

Smith  (H.  H.)  and  Horner's  Anatomical  Atlas 

Smith  (Edward)  on  Consumption 

Smith  on  Wasting  Diseases  in  Children 

?till6's  Therapeutics      .... 

Stille  &  Maisch's  Dispensatory    . 

Stnrges  on  Clinical  Medicine        .        . 

Stokes  on  Fever 

Tanner's  Manual  of  Clinical  Medicine 
Tanner  on  Pregnancy    .... 
Taylor's  Medical  Jurisprudence  . 
Taylor's  Principles  and  Practice  of  Med   J 
Taylor  on  Poisons  ... 

Tuke  on  the  Influence  of  the  Mind 
Thomas  on  Diseases  of  Females  . 
Thompson  on  Urinary  Organs 
Thomp.-on  on  Stricture  . 
Todd  on  Acute  Diseases 
Woodbury's  Practice     .... 
Walshe  on  the  Heart    .... 
Watson's  Practice  of  Physic 

Wells  on  the  Eye 

West  on  Diseases  of  Females 

West  on  Diseases  of  Children 

West  on  Xervons  Disorders  of  Children 

Williams  on  Consumption   . 

Wilson's  Human  Anatomy  . 

Wilson's  Handbook  of  Cutaneous  Medicin 

Wiihler'g  Organic  Chemistry 

Winckel  on  Childbed    . 


HENRY  C.  LEA'S  SON  &  CO.— Philadelphia. 


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